Frailty Phase 1 information for Federations/ West Essex Primary Care Provider organisations Imminent areas that require input with emerging primary care development plans (other than risk profiling and Primary Care MDT working)

Care Homes work stream Phase 1 investment has secured ability to recruit additional care home support nurses to become integrated into multi-professional care home support teams ( CHATs) Teams to consist of community matrons , dementia liaison support nurses and end of life care coordinators Aim to work alongside GP practices aiming to provide advanced care plans , annual reviews including medication reviews for all care home residents Integration with care home educational support pilot (PROSPER) funded by Essex County Council Aims to provide educational support and training for homes on key areas such as falls awareness and prevention, catheter care , prevention and management of simple infections such as UTI, prevention of dehydration (GULP tool) early recognition and management of delirium, constipation , incontinencee, pressure area care, nutrition, end of life care. Specific case support for residents in need of end of life care planning , dementia related problems e.g. challenging behaviour, long term condition support, etc. Recruitment of additional staff is in process. Aims to engage with all west Essex homes systematically, starting with top 12 homes with highest unplanned admission rates in quarters 1 and 2. Urgent need to link in with key primary care representatives within federations to shape integration with primary care plans - desired involvement/engagement in project team meetings to start June 2014

End of Life work stream Development of central EoL register (CQUIN) - enabler to earlier identification and intervention as well as providing important data sharing between primary care, hospice, community nursing ,acute trusts, SPA, social care , out of hours and ambulance service Care coordination pathway development - integration with hospice teams and provision of extra end of life care coordinators (in process of recruitment) to assist with multidisciplinary care planning throughout the patient journey Project team to involve key stakeholders: Hospice, primary care leads for end of life, SEPT teams, frailty project team, social care, ambulance service Monthly schedule of meetings to be set up imminently

Out of Hospital crisis care pathways Pathways are in process of development to support management of simple health crises in the community Cellulitis pathway (both via RACs and direct in patients homes) UTI pathways aligned to delivery of more care in community beds for step up care for the more complex (but non life threatening) cases Management of simple respiratory infections (low risk LRTI) and pathway for supporting mild exacerbation of COPD in patients homes and via community beds Falls reactive pathway - providing practical safe alternatives to A&E for same day assessment and management in the community for those patients who are NOT seriously injured or with potentially life threatening causes of falls.

Locality specific planning Mapping desired community geriatrics model for Uttlesford Health and Stellar Health Central risk register & regular direct sharing of information with practices of at risk persons (sharing of dependency registers, falls risk information, end of life care plans, case management, long term condition that community nursing teams have input into) Specialist regional community MDT working aligned to community geriatric support and mental health support with input from social care, frailty matrons and primary care for more complex brittle case planning and care delivery Access to and model for step up care delivery in intermediate care beds in Saffron Walden and at St. Margaret's, Epping. Integration with relevant acute trusts and existing acute trust services.

Next steps Plans to be shared/ developed on how provider organisations supported by CCG leads and Frailty Project team can communicate and engage directly with all member practices Preferred methods of communication with and input from provider organisations on key phase 1 work streams - monthly schedule of meetings of phase 1 projects due to start from June 2014 Named points of contact

Points of contact CCG: Dr David Tideswell CCG lead for frailty davidtideswell@nhs.net Lead provider Frailty Project team : Dr Sarah Zaidi ( Clinical lead for Frailty) sarah.zaidi@sept.nhs.uk Heather Beach ( Frailty Project Director ) heather.beach@sept.nhs.uk