Connecting 4 You Frailty Strategy High Weald Lewes Havens CCG. January Version 1.11 (170118)

Transcription

1 Connecting 4 You Frailty Strategy High Weald Lewes Havens CCG January 2018 Version 1.11 (170118)

2 Page 2 of 18 Contents Executive Summary.. 3 Why is Frailty a priority?. 3 Size and impact of problem... 4 Developing the integrated frailty pathway and strategy - vision and foundations 4 Integrated Frailty Pathway and elements of Strategy implementation.. 6 Strategic Aims 7 AIM 1- Age well and stay well. 7 AIM 2 - Live well with one or more Long Term Condition 7 AIM 3 - Support for complex comorbidities/frailty 7 AIM 4 - Accessible effective support in crisis AIM 5 - High quality person-centred acute care. 8 AIM 6 - Good discharge planning and discharge support.. 8 AIM 7 - Person centres, dignified long-term care.. 9 AIM 8 - Support, control and choice at end of life. 9 Delivery of vision and new integrated service models 10 Development of Communities of Practice and Multi-Agency Teams. 10 Development of HWLH Frailty Service 10 Enhanced Health in Care Homes. 11 Falls Service 12 Development of Dementia Golden Ticket. 12 Primary Care Home - Lewes Health Hub.. 14 Managing System-Wide change. 15 Strategic Governance and Delivery Indicators of Success Milestones References. 17

3 Page 3 of 18 Executive Summary The purpose of this document is to set out the Connecting 4 You Frailty Strategy for the next three years. The strategy covers the design and delivery of Frailty care for Adults in the HWLH CCG area. o o o It is recognised that no single organisation is able to meet all the needs of the frail population, to improve health, wellbeing and independence and a whole system approach and commitment is required to achieve our strategic aims. Our strategic aims are ambitious and require a collaborative approach across a wider range of key stakeholders; from health, social care, voluntary and third sector organisations, to patients and carers and our local communities. These collaborations will aid and support our own work and contribute to improving outcomes in Frailty Care as we deliver our vision of excellent integrated Frailty Care. Introducing a comprehensive Integrated Frailty Pathway supports delivery of the CCG and Connecting 4 You partner s vision for frail elderly care and integrated community services. It supports and contributes to a more proactive model of care, utilising an inter-disciplinary approach, and improving the interface between acute and community services. Why is Frailty a priority? Our population is changing and whilst the core challenges facing the Connecting 4 You health and social care system are neither new nor unique, the urgency and need for transformation and the financial challenge is at a critical point. Approximately 10% of people aged over 65 and 25-50% of those aged over 85 are living with frailty. Older people are the main users of health and social care services and health and care services have failed to keep up with this dramatic demographic shift. The Connecting 4 You programme Partners - who oversee, design and deliver care services to meet the needs of the CCG population - support Frailty as a priority area and recognise the following as the key drivers for change: Demographics of our local population - increasing age and socio economic profile Current lack of a joined up Frailty service Workforce challenges and gaps in provision Care is not currently delivered in the most appropriate place close to home Recognition that secondary care is not the right environment for our frail population Affordability of the current model - health and social care funding is not increasing in line with increasing population demand A person centred integrated approach to provision of services is evidenced to improve patient outcomes and experience as well as make best use of valuable resources and reduces unplanned admission.

4 Page 4 of 18 Size and impact of problem The proportion of the UK population aged 90 or over has been steadily increasing since the early 1980s. The percentage of the population aged 65 and over was 17, 7 % in 2014, and is predicted to be 19,9 % in 2024 and rising to 23,3 % in Between % of people older than 85 are estimated to be frail, with overall prevalence in people aged 65 and over approximately 10%. Nationally, 59% of readmitted patients are 65+ and 10% of 65+ will be readmitted within 30 days. HWLH has an older population compared to England with a significantly higher percentage of older people aged 65 years and 85 years and over. With a rapidly ageing population, population projections showing that the proportion of older people will continue to increase and an associated increasing number of people living with complex long-term conditions and frailty, hospitals are experiencing high levels of emergency activity and delayed transfers of care. Against this backdrop, the prevalence of depression and dementia are both higher than the England average in addition to higher percentages of emergency admissions for people who are terminally ill. HWLH CCG has 20 GP practices providing healthcare for a population of 170,087 (October 2017) (20%) of the HWLH practice population are over 65 years old and 5375 (3.2%) over 85 years old. Staff in care homes are now looking after the same acuity of person as nursing homes were 3 years ago. People over 75 in a care home are 45% more likely to have either an unplanned admission or A/E attendance than those not in a care home. A third of these people die during their admission and 40% die within 6 months. Frailty in a care home environment is the most common cause of death (27.9%) compared to organ failure (21.4%), cancer (19.3%) and dementia (13.8%) Transforming services for older people requires a fundamental shift towards care that is coordinated around the full range of an individual s needs (rather than care based around single diseases) and care that truly prioritises prevention and support for maintaining independence. Achieving this will require integrated working to ensure that the right mix of services is available in the right place at the right time. Developing the integrated frailty pathway and strategy vision and foundations As local clinicians and health and social care partners, we are committed to ensure that our frail population receives safe and high quality care to meet their individual needs. In addition, we are committed to challenging the strictly disease-orientated biomedical approach taken to many other long-term conditions and ensure that interventions for our frail patients are aimed at improving physical, mental and social functioning to avoid adverse events, such as injury, hospitalisation, and institutionalisation. Our frail residents should receive compassionate care enabling them to feel safe and supported and to live independently for as long as possible. Care should be planned and delivered in full consultation and partnership between the individual, their family and carers; and service providers.

5 Page 5 of 18 That means good communication, coordination of care, and skilled and evidence-based interventions. To realise this vision, we have aligned and based our integrated frailty pathway and strategic aims on an international and national evidence base and guidance, in addition to local evidence and priorities identified at a Frailty Event held in May 2017 for system partners across health, social care and the voluntary sector. We have also tested out our approach at our patient and public shaping health listening and engagement event held in September This research and engagement has informed our philosophy of care, design of the integrated pathway and strategic aims and are listed in the reference section of this document. Key themes and priorities identified: Risk Stratification Integrated Patient Records Rapid Response Interventions Falls Prevention & Response Enhanced Health in Care Homes Medication Reviews Advanced/Future Care Planning Improved Streamlined point of access Care Coordination Self Help Workforce support and advice Development of a Frailty Nurse Specialist Service Community Geriatrician Service Roll-out across HWLH CCG Close alignment with Dementia Golden Ticket The pathway should be seen as a whole, delivered by one integrated system and describes: o Integrated services to provide person-centred frailty care o Enablers/What we know works from local/national evidence o Current delivery in HWLH CCG o Gaps in provision/frailty projects in progress

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7 Page 7 of 18 Frailty Strategy and Strategic Aims This strategy describes the work that High Weald Lewes Havens CCG is leading and coordinating to deliver its strategic aims which are aligned to the Kings Fund Making our health and social care system fit for an ageing population (Kings Fund 2014). While this is a local delivery strategy we acknowledge the need for close partnership working to ensure the seamless delivery of high quality frailty care by multiple agencies. We will continue to work closely with partners within both our local and wider healthcare economies to improve and develop our integrated frailty partway and frailty care outcomes. Strategic Aims: 1. Age well and stay well 2. Live well with one or more Long Term Condition 3. Support for complex comorbidities/frailty 4. Accessible effective support in crisis 5. High quality person-centred acute care 6. Good discharge planning and discharge support 7. Person centred, dignified long-term care 8. Support, control and choice at end of life Strategic Aims for the integrated Frailty Pathway AIM 1 - Age well and stay well AIM 2 - Live well with one or more Long Term Condition AIM 3 - Support for complex comorbidities/frailty What we know works well Continuity of care / care coordination Population risk stratification Integrated locality based teams delivering case management Involving older people / their family / carers in their own care Personal care budgets and direct payments Telehealth

8 Page 8 of 18 Building blocks to achieve our ambition: Carer Support Navigator Services Housing Advice Benefits Advice Money Advice Health Coaching Social Prescribing Self-management Shared Decision-making Community Voluntary Sector Involvement Patient Education Fire Service Home Safety Visits AIM 4 - Accessible effective support in crisis AIM 5 - High quality person-centred acute care AIM 6 - Good discharge planning and discharge support What we know works well Support and education for family and volunteer carers Ensure older people receive the same support as younger people with same condition Improve care and treatment for the common conditions of ageing Holistic assessments Comprehensive local Directory of Services for patients and professionals Streamlined Single Point of Access Building blocks to achieve our ambition: Primary care Risk Stratification/Frailty Element GP contract Frailty Service & team support to GPs in the management of complex frail patients Comprehensive Geriatric Assessment (CGA) Community Service / Multi-Agency Teams Rapid response interventions and clinics Intermediate care services & step-up / down beds Emergency and planned social care Home care services Integrated Physical and Mental Health care Dementia Golden Ticket Occupational / physio / speech & language therapy services Community diagnostics

9 Page 9 of 18 Integrated patient record Integrated Pharmacy Team Interface with acute sector / ED Clinical Frailty Assessment Shared Care protocols and triaging ambulance/acute and community Telehealth AIM 7 - Person centred, dignified care AIM 8 - End of life support, control and choice What we know works well Recognising the importance of frailty / risk assessment and case finding Proactive CGA and follow-up for people identified as frail Exercise for frail old people, falls prevention and fracture liaison High quality, timely dementia diagnosis, management and post-diagnosis support Good rehabilitation and re-ablement after acute illness or injury Primary Care continuity & urgent access to Primary Care Urgent co-ordinated Social Care Shared care strategies with other services Community and interface geriatrics Building blocks to achieve our ambition: Enhanced Health in Care Home Project Support and training to nursing/care home staff Strengthening co-ordination and discharge planning/early supported discharge Out-of-hours service Improved information sharing Specialist Nurses Transport Falls service Comprehensive end-of-life assessment and advance care planning Supporting care home residents to die in the care home rather than in hospital

10 Page 10 of 18 Delivery of vision and new integrated service models Effective provision for the frail/elderly population will be delivered through an integrated service model which has the following characteristics: Whole system approach Proactive identification and care for frail/elderly patients at every stage of the pathway through Risk Stratification Resilient Primary Care and General Practice service Single Community of Practice (CoP) with a functioning integrated health and social care Multi Agency Team (MAT) in each Community of Practice Frailty Service supporting each Community of Practice Enhanced Health in Care Homes service supporting all nursing homes Design, procurement and implementation of a comprehensive Falls service offer and pathway Dementia Golden ticket available for CCG population with Dementia MATs Development of Communities of Practice and Multi-Agency Teams Single Community of Practice (CoP) per 30 50k registered primary care list. GP Practices are developing individual Multi Agency Teams (MAT s). Empowered local teams allowed to develop and respond to their population needs, whilst adhering to the same core principles. There is no one size fits all. Effective relationships, communication and leadership is vital Frailty Team (Community Geriatrician & Frailty Nurse Specialist) support to each CoP is critical and should provide a named link to each MAT Other specialist support will ordinarily sit outside the core MAT, but must actively support and enable the MAT Using Live and Dormant lists drawn from the Risk Stratification scoring, ensuring manageable case loads Development of a HWLH Frailty Service Key components of comprehensive Frailty Service; Coordinated care wrapped around the patient that follows the patient into and out of the acute hospital back into the Community, bridging the entire urgent care and planned pathway - health and mental health wellbeing Proactive model of care with an inter-disciplinary approach Specialist geriatric workforce supporting the whole system Frailty Nurse Specialists Geriatricians provide key leadership role in the system Providing support, training and education for the system

11 Page 11 of 18 Phased approach in HWLH; Implementation of Service across the whole CCG from January 2018 HWLH Community Geriatricians Service Phase 2; Extension and expansion of current Community Geriatrician Service delivered by BSUH, offering a comprehensive service to the Lewes, Havens and Uckfield Communities of Practice from October Launch of Community Geriatrician Service delivered by MTW covering the Crowborough Community of Practice, from October Enhanced Health Care in Nursing Homes The EHCH model is based on learning from six national vanguards. The model is based on a suite of evidence-based interventions, which are designed to be delivered within and around a care home in a coordinated manner to improve and optimise the management of nursing home residents with complex needs. Key Care Elements; Enhanced Primary Care access and support to Nursing home staff and patients Better integrated services / service provision between Primary Care, Community Services, nursing home sector patients A weekly proactive Home Round by the core contestant team, usually a GP and senior nursing home nurse, ensuring an up to date care plan for patients Annual full medication reviews of all nursing homes, which seek to reduce the use of unnecessary and sometimes harmful medicines as well as reduce the costs associated with medicines waste. Medicines management advice / input as needed Re-ablement and rehabilitation High quality end-of-life care and dementia care Workforce development and education of nursing home staff Data, IT and technology Phased approach in HWLH; Service provided to one nursing home in each cluster November 2017 Service provided to 50% of nursing homes in HWLH February 2018 Service provided to all nursing homes and care homes in HWLH May 2018 Evaluation from December 2018

12 Page 12 of 18 Falls Service We plan to develop an improved falls service offer and pathway for HWLH patients, based on NICE guidelines and evidenced good practice. The scope of the falls service covered by this will comprise of the following proactive elements: identification of falls risks prevention - of falls promotion - of good bone health response and rehabilitation (non-fracture) following falls fracture liaison following falls carer support for all aspects of the service offer and path The key care elements of the service will comprise: multi-factorial assessments, interventions and reviews home and group based strength and balance exercise classes targeted care home support fracture liaison service formal pathway for access to non-weight bearing beds Development of Dementia Golden Ticket The Dementia Golden Ticket is a multi-agency, holistic approach to diagnosis and post-diagnosis care for both the patient AND the carer. It includes assessment by a Secondary Care MDT (Multi-Disciplinary Team) and diagnosis by the same team, in peoples own homes, resulting in the issue of a Golden Ticket. This prescribes a social treatment plan, facilitating access to a Dementia Guide and a range of community interventions including: Exercise Classes Musical Moments Memory Wellbeing Cafés The model includes post-diagnosis review meetings in Primary Care, weekly proactive Blip clinics and holistic 6/12 monthly reviews Advanced Decision Making and Advance Care Planning are key components in the Primary Care and Dementia Guide interface

13 Page 13 of 18 Dementia Golden Ticket Frailty Advice Telephone Line 12-2pm Daily GP/Nurse Access to Adult Social Care Crisis Response Review Meeting GP Referral Multi-Agency Team Psychiatrist/Geriatrician Clinical Nurse Specialist Clinical Psychologist Neuropsychologist Community Psychiatric Nurse Occupation Therapist Speech &Language Therapist Administrators Support Worker Team Leader/Frailty Nurse Social Worker Input Dementia Guide input GP phone in for individual case discussion Diagnosis at home by same Team Member Bloods Letters PROACTIVE AND AWARE Named Team Member Assessment at Home Primary Care Reviews Dementia Guide Blip Clinics Patient AND Carer Support Well-being Interventions Advanced Care Planning Admiral Nurse Communities of Practice Multi-Agency Team GOLDEN TICKET

14 Page 14 of 18 Primary Care Home Lewes health hub Home of care for a population focusing on population health, personalisation, provision of care and outcomes: An integrated, multi-disciplinary workforce Financial drivers aligned with the health needs of the whole population Long term continuity retained with continuous care teams Allows for a much more individualised care and approach Integration with other providers of care in the wider local health community Provides a single point of access for health and care needs Provided at a number of sites comprising the Lewes Health Campus.

15 Page 15 of 18 Managing System-Wide Change Creating a new model of care for the frail / elderly population as described in this strategy document requires transformational change across the system. In realising such change, we are applying the following principles of large scale change: o o o o Identifying high leverage key themes that explain the need for change and describe it in a way that people can understand e.g. the need for integration because patients experience fragmentation. Spending time with people, ensuring that change processes provide the opportunity to frame and reframe issues actively because different people and groups see things from different perspectives and will have different receptors for change. Supporting wide ranging and active engagement of stakeholders. Creating momentum through early, pragmatic and mutually reinforcing changes across multiple systems and processes to gather champions and spread different ways of working e.g. develop sites with excellent practice and share learning. Strategic Governance and Delivery Indicators of Success The Connecting 4 You (C4Y) Frailty Steering Group, reporting to the C4Y Programme Board, has responsibility for the development and review of our Frailty services and therefore oversees the progress and delivery of the strategic vision, milestones, and new models of care. High level indicators of success, aligned to outcomes, include: Delivery of high quality Frailty Care and associated outcomes and milestones across HWLH Positive feedback and plaudits from patients and carers Reduction in non-elective admissions for those over 75 25% Reduction in A/E attendances for those over 75 25% Reduction in length of stay for those over 65 Reduction in Delayed Transfers of Care (DToC) Significant reduction of admissions for LTC in all age groups Significant reduction in readmissions Increase in people dying in their place of choice Significant reductions in people in long-term residential placements High satisfaction scores in patient and carer experience surveys Each C4Y partner organisation has individual responsibility and governance arrangements for sharing the vision within its organisation.

16 Page 16 of 18 Milestones Sept 17 Oct 17 Nov 17 Dec 17 Jan 18 Apr 18 May 18 Oct 18 Dec 18 Feb 19 Apr 19 May 19 Aug 19 Oct 19 Establish project x teams and governance arrangements C4Y Frailty x Steering Group formed and functioning C4Y Programme x Board formed and functioning Baseline data x produced and fit for use Delivery Plan x costed and agreed New Models of care start x x x COP/MAT s x x x x Frailty Service x x x x x EHCH x x x x Falls service x x x Dementia Golden Ticket Primary Care Home New Models of Care fully operational x x x x x x

17 Page 17 of 18 References 1. Avoiding hospital Admissions. What does the research evidence say? Kings Fund Beswick, et al. Complex interventions to improve physical function and maintain independent living in elderly people: a systematic review and meta-analysis. Lancet Mar 1; 371(9614): Briggs R, McDonough A, Ellis G, Bennett K, O Neill D, Robinson D.Comprehensive Geriatric Assessment for community-dwelling, high-risk, frail, older people. Cochrane Database of Systematic Reviews 2017, Issue 6. Art. No.: CD DOI: / CD East Sussex Joint Strategic Needs & Asset Assessment. High Weald Lewes Havens CCG. East Sussex Public Health Ellis G, M Whitehead, A Robinson, D O'Neill, D Langhorne. Comprehensive geriatric assessment for older adults admitted to hospital: meta analysis of randomised controlled trials. BMJ 2011 Oct 27;343:d6553.doi /bmj.d Carlill, G. The Falls and Frailty Response (FFR) new ways of working with older people. Journal of Occupational Therapy 2017; 80: Case Management what is it and how can it best be implemented. The Kings Fund Clegg, A., Bates, C., Young, J., Ryan, R., Nichols, L., Teale, E. A., Mohammed, A.M., Parry, J., Marshall, T. Development and validation of an electronic frailty index using routine primary care electronic health record data. Age and Ageing 2016; 45: Collard et al (2012) Prevalence of frailty in community-dwelling older persons: a systematic review. J Am Geriatr Soc., 60 (2012), pp Five Year Forward View. NHS England Frail elderly care pathway results in a seamless service. Nursing Standard Jan 15-21;28(20): Huss, A., Stuck, A. E., Rubenstein, L. Z., Egger, M. Multidimensional Geriatric Assessment: Back to the Future. Multidimensional Preventive Home Visit Programs for Community-Dwelling Older Adults: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Journal of Gerontology: MEDICAL SCIENCES. 2008, Vol. 63A, No. 3, Innovative models of care delivery in general practice. The Kings Fund Lisk, R., Yeong, K., Nasim, A., Baxter, M., Mandal, B. Nari, R. Dhakam, Z. Geriatrician input into nursing homes reduces emergency hospital admissions. Archives of Gerontology and Geriatrics, Volume 55, Issue 2, Pages Making our health and care systems fit for an ageing population. The Kings Fund Office of National Statistics. Overview of the UK population: March Older people and emergency bed use. Exploring variation. The Kings Fund Philips, I. Four principles to improve the care of older patients. Health Service Journal Recognising and managing frailty in primary care. National Institute for Health Research (NIHR). 2015

18 Page 18 of Safe, compassionate care for frail older people using an integrated care pathway: Practical guidance for commissioners, providers and nursing, medical and allied health professional leaders. NHS England The Future of GP Collaborative Working. Royal College of General Practitioners Transforming Primary Care - Safe, proactive, personalised care for those who need it most, Department of Health. 2014