Sutton Homes of Care Vanguard Programme   Wandsworth registered managers forum Wednesday 29th March 2017 Caroline Pollington, Lead Nurse

Five Year Forward View Published 2014; set vision for Vanguards Sutton awarded 1 of 55 Vanguards; 1 of 6 Enhanced Health in Care Home Vanguards Annual Value propositions; funding released subject to conditions

Our Partners … All our Care Homes in Sutton Sponsored by: The National Institute for Health and Care Excellence (NICE) … All our Care Homes in Sutton Working in collaboration with: NHS England New Care Model Programme SWL Collaborative Commissioning Care Quality Commission Health Education South London Health Innovation Network Academic Health Science Networks Other Care Home Vanguards Breaking down organisational boundaries – form vs function Do with not to the care homes

Overview: The population of Sutton 80 Care Homes 594 residents in NHS Funded Nursing Home placements 203,048 Residents in Sutton 14166 aged 75+ 4450 aged 85+ 1213 Care Home Beds £10 M Fully funded nursing home placements Health funded home care packages Specifics on our Care homes 25% stat funded, Older People, LD context, old houses, importer of residents 1770 A&E presentations from Care Homes 1034 Emergency Admissions £1.1M 275 people were eligible to receive Funded Nursing Care

The Challenge for Care Homes Independent organisations Barriers to engagement Recruitment and Retention Terms and conditions are not standardised Negative attitudes What happens if a care home closes? Most Frail and vulnerable members of society Myths and limitations of NHS support “not in their own home” Large number of beds but limited statutory controls

What we have achieved Impact on residents Impact on NHS Care: 9% reduction in ambulance call outs and conveyances 18% reduction in A&E attendances and 9% reduction in unplanned admissions 4 days reduction in length of stay in hospital (results from preliminary evaluation of Hospital Transfer Pathway) Reduction of £100k in medicines costs from Sept 15 to Sept16 through resident medication reviews Impact on Clinical Quality 10% reduction in pressure ulcer rates and 15% reduction in falls rates (AQP data) Reduction in UTI rates following introduction of resource packs (AQP data) Impact on End of Life Care 75% of residents offered CMC 60% of residents with a CMC record 89.6% of residents with a CMC record achieve PPD

What we have achieved Genuine partnership and collaborative working enabling enhanced communication and more joined-up services Bi monthly care home forums for care home mangers Positive impact on care home staff work roles Engagement with residents and families Contribute to Dementia Diagnosis Rates Collaborative working with other five care home vanguards: Embedding EHCH Framework into practice National and International Publications; Award finalists Presentations at Pan-London and National conferences; Visits from NICE, DOH, Ministers and Dignitaries Shoe leather, time, meet the managers

Sutton Homes of Care: The programme NEW MODEL OF CARE Our vision is to have a vibrant, high-quality care home market in Sutton delivering care that embraces the national nursing values of patient care – Care, Compassion, Competence, Communication, Courage and Commitment (the ‘6Cs’). NEW MODEL OF CARE Integrated Care Care Staff Education and Development Quality Assurance and Safety The vision is implemented through the three ‘pillars’: Integrated Care Care Staff Education and Development Quality Assurance and Safety Discuss name of the programme (don’t like abbreviation)

Registered managers forums The starting point- 2014 Registered managers forums Building networks between care homes and partner organisations Building relationships https://www.youtube.com/watch?time_continue=1&v=3_bTeMCJ4ks

Care Staff Education and Training Pillar www.suttonccg.nhs.uk/vanguard Training / Education E-learning packages Classroom based training Bespoke interventions from link staff Student nurse mentorship training underway Summary of resources Concerned About A Resident poster Priorities ‘For Care of the Dying Person’ poster Red bag poster and film Quick Guides (reference cards, A3 and A5 posters), posters and film Care Home Forums

Care Staff Education and Training Pillar Staff trained using dementia case finding tool DeAR GP Staff trained on Barbara’s Story - dementia training film by guys Staff trained on how to do a music mirror for each individual resident Silver Letters is being rolled out across our care homes – part of Silver Line Dementia Awareness DeAR GP Barbara’s Story Music Mirrors Silver Letters

Integrated Care Pillar Health and Wellbeing Reviews - Pilots in 6 Nursing Homes and 4 residential homes Care Home Support Team Link Nurses / EOLC Nurses / Pharmacy / Dementia Support Workers / dietician Link nurse led weekly reviews and champion role development

The hospital transfer pathway https://www.youtube.com/watch?v=XoYZPXmULHE

How did it all start? Issues identified No standard paperwork Lost documents Loss of residents’ belongings Medicines disappear No system in place to track residents through the hospital Care homes find it difficult to get information from hospitals Care homes receive lots of phone calls about the residents’ clinical ‘situation’ Poor communication between hospitals and care homes on discharge Residents staying in hospital for longer periods than necessary Solutions proposed Transfer bag Standard paperwork to assist ambulance staff and A&E staff Baseline information about the resident Better communication between care homes and hospitals at all points of the resident’s journey Senior staff from care homes to visit residents in hospital within 48 hours of admission

The actual handover C: Concerns A: Actions S: Situation R: Response E: Examination S: Shared Information S: Situation B: Background A: Assessment R: Recommendation Most important things we need to know: What is happening to the resident now? What has changed from previously?

The standardised paperwork CARES Handover Process Older Persons Assessment Form For baseline information CARES Escalation Record To capture the acute episode This is Me (or equivalent) MAR Sheet

Advantages for care homes Saves you time Baseline information would be up to date, only need to complete the current episode, i.e. why they are going to hospital Smoother handover to ambulance Less time spent on phone with hospital During admission because they have all the necessary information After discharge because they have included updated clinical information and TTOs Enhances resident experience Personal aids available to resident and a change of clothes to come home in Less likely to lose property and personal aids Treated with dignity and respect due to information required e.g. ‘this is me’ Identified as a care home resident and the appropriate steps can be taken by all hospital staff Enhances continuity of care during admission and after discharge Resident comes home quicker instead of an unnecessary long stay Opens lines of communication resulting in much better working relationships with hospital staff

Supports best practice Standard documentation enhances clinical decision making and resident safety Improves residents’ experience Supports collaborative working and communication Aids early discharge and involves care homes in discharge planning National guidance NICE Guideline 27: Transition between inpatient hospital settings and community or care home settings for adults with social care needs NICE quality standard [QS120] Medicines optimisation CQUIN Indicator N2: Reduction in Emergency Admissions.

Advantages for ambulance and hospital staff Smoother handover from care home and to hospital Standardised paperwork between care homes easier to use More informed and quicker clinical decisions Patient-centred care as documents highlight needs, wishes and risks (e.g. DOLs, CMC) Residents property contained Good communication and better relationship with care homes Smoother discharge process Time efficiencies

Great care for our residents Sarah on at 02:05 – 05:21 Perspectives A care home resident: https://youtu.be/MP03jUtBXmA A care home manager: https://www.youtube.com/watch?v=aOmd00dE6mI

Demonstrable impact to date 179 residents of care homes have been tracked through our local hospital in the last nine months Average length of stay with a bag was 13.4 days, compared to 17.4 days without a bag Residents with a Red Bag spent 4 days less in hospital than those without a Red Bag Note: Data kindly collected by Integration and Transformation Team and Oder People Nurses at our local hospital

“Definitely helpful for the acute take” Feedback “Patient can be aggressive but tips included about talking to him about his wife and has been so much easier to care for him. Might usually take 2 hours to find out this information and sometimes might never find out!” “A good organised comprehensive approach enabling clinicians to obtain a complete picture, especially in cognitive impairment.” “I didn’t know the patient was on thickener [for drinks] until I looked through the Red Bag” “Definitely helpful for the acute take”

17/18 Plans Targeted work with Learning Disability and Mental Health Homes Testing schemes in Assisted Living homes – Purple Bag Scheme Training and Education for Domiciliary Care Agencies Piloting of tele-health “pods” in residential and Assisted Living homes Focus on Nutrition Reducing Pharmacy waste Out of Hours support Directory of Services to support Care Homes Sharing Learning and replication of model Inputting into the SWL STP; build on collaborative sharing programme with HESL across SWL.

Sutton Homes of Care Great care is a partnership Equity Equality Empowerment More information is on our website: www.suttonccg.nhs.uk/vanguard