Inspiration Day Thursday 21st March 2019

House Keeping Fire alarm, exits and muster point Toilets Phones Photography Timings for the day- Workshops Breaks, lunch and refreshments Feedback forms #Best4ESTHER

Dr Robert Stewart- Clinical Design Director of the Design & Learning Centre Anna Carlbom- ESTHER Lead- Design & Learning Centre Dr Sarah MacDermott-Clinical Chair of DGS CCG

ESTHER Philosophy in Theory “What matters to you?” ESTHER Inspiration Day 21 March 2019 Dr Robert Stewart Clinical Design Director Design and Learning Centre for Clinical and Social Innovation Anna Carlbom ESTHER Lead Design and Learning Centre for Clinical and Social Innovation

Design & Learning Centre for Clinical & Social Innovation Co-Designing Better, Safer, Cheaper and Different Care An Innovation Space for Professionals, Citizens, businesses & academics Finding the right solutions to make a real difference Supporting the 2 million people in Kent, Medway and Beyond A better and cheaper way! Removing organisational & professional barriers

ESTHER Philosophy of Care culture strategy services

Bringing together culture and strategy with better outcomes 5 Levels of Continuous Quality Improvement Changing culture and strategy for better outcomes Bringing together culture and strategy with better outcomes M ESTHER Cafe Coach Trainer Ambassador

International philosophy co-implemented across Kent and Medway Concept from Sweden Co-implemented in Thanet CCG Planned in DGS and Swale CCGs Singapore collaboration

International philosophy co-implemented across Kent and Medway Concept from Sweden

Concept from Sweden 1 2 3 Why did Sweden develop the ESTHER Philosophy? How did Sweden implement the ESTHER Philosophy? What outcomes did the ESTHER Philosophy achieve?

https://vimeo.com/318398646/5f0b6caf9d

Co-implemented in Thanet CCG

Co-implemented in Thanet 1 2 3 Why Thanet? How did Thanet co-implement? What has Thanet achieved? ART successful Local perspective

Planned in DGS and Swale CCGs

Planned in DGS and Swale CCG 1 2 3 Why DGS? Using ESTHER as the OD tool for MDTs Planned implementation DLC developing local capability What timescales? Has started with Ambassadors, Coaches,Trainers and Cafes

Implementation in DGS (Dartford Gravesham and Swanley) Governance – Local Care Implementation Committee Stakeholder organisations to nominate an ESTHER trainer MDT Co-ordinators job specification includes: ESTHER positive ESTHER Ambassadors ESTHER Café organisation in each MDT quarterly Design and Learning Centre co-locating ESTHER resources Aim - 10 local trainers DGS and Swale by July 2019 Aim – Reach 1500 health and care professionals by 2020 Core to the organisations providing health and social care including core induction initially Virgin and KCC

Singapore collaboration

Singapore collaboration 1 2 3 Implementing together with Sweden as three sites learning and supoorting Hosted visits Regular international webinars Developing joint ideas in evaluation and clinical co-operation

ESTHER Philosophy of Care “What matters to YOU?” Local clinical leader’s perspective Dr Sarah MacDermott Clinical Chair and local GP, DGS CCG Dartford Gravesham and Swanley Clinical Commissioning Group

ESTHER Philosophy of Care “What matters to YOU?” Developments e-learning Carers app External connections in UK and internationally Any reflections, inspirations and questions from you?

What difference has ESTHER already made?

System learning - Informed East Kent Frailty Strategy Raised priority of person-centred care Many small improvements – Little things matter! Improved ESTHER & care professional individual experiences Empowering self-care Transforming MDTs, Primary Care Networks and Communities

Anna Wilson- Local Care Commissioning Programme Manager DGS

MDTs in DGS – the patient centred approach

MDT localities 6 localities across Dartford, Gravesham & Swanley (30-50k patients each) Staff aligned to localities from multiple health & social care providers 3 MDTs are ‘live’. Remaining 3 planned to go-live throughout April Weekly MDT meetings with GPs managed by MDT Co-ordinators (currently CCG staff) Patient nominations welcome – actively working through GP frailty lists and focussing on elderly, frequent attenders at A&E

Patient example - MD 71 year old female FRAILTY SCORE of 33, which equates to ‘MODERATE FRAILTY’ Multiple LTCs: COPD TYPE 2 DIABETES CHRONIC KIDNEY DISEASE CHRONIC LOWER EXTREMITY OEDEMA NEW ONSET RECURRENT FALLS NEW ONSET COGNITIVE DECLINE

MD’s social history SOCIAL HISTORY: Widowed Lived alone in 2 storey house with upstairs bedroom Help from Neighbour who was assisting with finances, home modifications and direct patient care There were some safeguarding concerns around her care

MD in crisis MD had an emergency admission to Hospital in October 2018 (as MDTs were launched) – this was for a lower respiratory tract infection and dehydration. Home therapy previously in place had failed and social vulnerability had been identified by the GP MD was discharged to an intermediate care unit after 24 hours in Hospital and she stayed in intermediate care for 20 days to rehabilitate MD was placed on the community nursing caseload when she returned home as she was a housebound patient Anna

So what did the MDT do? We discussed MD after the GP nominated her. We agreed, as a team, the GP would contact the patient and discuss/initiate care while MD was still in the intermediate care setting – discharge date was agreed with staff and MD A medication review was undertaken by the GP upon discharge – medications optimised for lower extremity oedema A home visit was undertaken by the community matron to review MD’s LTC management. COPD therapy was optimised, a Diabetes review was undertaken and this is now well controlled. GP was notified of incontinence and a prompt referral and assessment was initiated MD was reviewed by a community navigator and social services – an assessment of vulnerability/safeguarding was undertaken in the patients home. MDs care needs were assessed and the patient wished to be supported individually in her own home

How has this helped MD? LTCs now well controlled – MD has been discharged from the community matron caseload MD continues with housebound care via a number of services A recent emergency admission for Anemia due to GI bleed resulted in a six day stay for investigation and treatment. MD was then discharged home successfully to continue with her current care plan

How has this helped the MDT? Everyone in the same room, at the same time, discussing the same patient - effective communication & very patient focussed Immediate updates from a number of different providers Urgent actions taken away by staff and followed up as required MDT coordinator able to keep track of the patients journey and relevant actions for the group etc

ESTHER café’s We are working with our ESTHER colleagues to arrange ESTHER cafes in DGS throughout April/May A small selection of practices have been chosen to provide case studies for us to focus on – patient consent will be gained Plan is to hold at least one ESTHER café, once every quarter, in each of the 6 DGS localities

Local Care Commissioning Programme Manager - Anna Willson Both Local Care Commissioning Programme Manager - Anna Willson Anna.Willson@nhs.net 03000 424912

Ann Taylor- Chief Executive- Hilton Nursing Partners

Home To Decide Esther Philosophy in Practice Ann Taylor CEO Hilton Nursing Partners anntaylor@hiltonnursingpartners.org.uk 07715 014086

How I Met Doris

Can I Come Home?

Out of that hospital gown

Home for Manicure & Wine

But Doris didn’t have family: Lived alone Assessed for Nursing Home Placement in Hospital Frail, elderly and worried Her concerns: Did I shut the front door? What about telling my friends and neighbours Where is my handbag? Is this how it all ends??????

Benefits of Esther: To support people who believe they are capable of returning home. To allow people and their families time and space to make informed decisions about future care. To provide one high quality, person centred trusted assessment in the right place - HOME. To provide support, advice and advocacy to people and their families regarding ongoing options available. To reduce unnecessary residential care admissions.

Esther’s Journey: Esther is likely to remain living independently at home for longer. Esther and family are given time and space to fully consider all options. Esther receives a more appropriate assessment at home. Esther is no longer a DTOC or ‘stranded’ patient. Esther is in control and has choice. Esther has been given her life back!

Case Study: Admitted to hospital with a fracture that could not be surgically repaired. Main carer was his daughter who was living with her own disabilities. Heading for residential care – as would be bedbound and deemed as unsuitable to return home, due to other complex health conditions. Eager to return to his daughter – a co-dependant relationship. Was referred to Home to Decide. After his Hilton journey, this man was able to remain at home with his daughter – his only wish. A package of care was implemented alongside Carer Support and Telecare assistive technology.

Feedback I wanted to thank you for recently looking after my Dad, who was admitted to hospital in February, following a fall and with a chest infection. I did not know your service existed, but with the 3 days, 24hr support, followed by regular calls supplied by you, this allowed us to set him up at home, where he now continues with private care. Excellent service from a great team. Having this service allowed me the time to make the best decision with Dad.

Feedback All of your nurses/carers looking after my mother at her home were excellent in every respect. They were all thoughtful, kind, patient and professional under Claire’s guidance. Also, a special thank you to Claire, for giving me much needed emotional support. The girls deserve a thank you for their positive contribution to the company. Well done.

Cathy Bellman- Kent and Medway STP Local Care Lead

Esther Inspiration Day Local Care - ESTHER Philosophy in Practice 21 March 2019

Local care: The Kent and Medway Sustainability and Transformation Plan outlines the intention of the Kent and Medway health and care system to deliver an integrated health and social care model that focuses on delivering high quality, outcome focused, person centred, coordinated care that is easy to access and enables people to stay well and live independently and for as long as possible in their home setting. Additionally, the Kent and Medway Case for Change states that the first priority is to develop more and better Local Care services; Local care being the delivery of integrated health and care services close to where people live, with A collective commitment of the health and care system in Kent and Medway to fundamentally transform how and where we will support people to keep well and live well.

The Model is Patient Centred Care: Our ESTHER in Kent and Medway is ‘Dorothy’ This will be achieved by the single point of access, an integrated health and social care MDT, liaison with specialist services and other supporting services Local care already happening in places across Kent e.g. Encompass, Thanet Primary Care Homes Between now and 2021 all of Kent and Medway having implemented all of care models Starting in different places Localities providing services to 30 to 50k 29 in total Groups 1, 2, 3

This will be achieved through Multi-disciplinary Team (MDT) Working We aim to put ‘Dorothy’ (ESTHER) at the heart of their own care. By asking, “What matters to you?” Prevention and self care Community pharmacists Acute mental health care Consistent high-quality acute care Rapid response Integrated health and social care at home Care co-ordination Therapists Dementia nurses Diagnostics Mental health Single point of access To; prevent ill health intervene earlier support wellbeing and independence deliver integrated care closer to home. Use these slides to answer the three set questions …. Source: K&M STP

Who’s in an MDT? Additional members which vary locally: Shared IT is essential to communicate effectively A core MDT team includes: Mental Health worker GP Health and social care coordinator Community nurse / LTC Nurse Pharmacist Geriatrician Social Prescribing Administrator Nurse Specialist Allied Health Professional Our Integrated Case Management (ICM) Approach Agreed with patient/carer Care plan Social Care representative / social worker Care worker Additional members which vary locally: Fire and rescue Police Acute specialists Integrated Discharge Team Local Government i.e. housing

Our eight ambitions for ‘Dorothy’ (ESTHER) Implementing local care Our eight ambitions for ‘Dorothy’ (ESTHER) Our ultimate aim for older people is to support their needs better and stop them going into hospital. We know that every day in Kent and Medway around 1,000 people are in a hospital bed when they don’t need to be or want to be. Some of the reasons why older people stay too long in hospital are: they have to wait for care to be in place to support them going home they need a social care assessment or an occupational health assessment or they need a residential home place. To illustrate how we would like to improve care and treat more people at home, we’ve created ‘Dorothy’, an example patient. By demonstrating what we think her care should look like, we can look at how our proposed model might work. So imagine Dorothy is 79, and frail. She has type 2 diabetes, Chronic Obstructive Pulmonary Disease (COPD), memory loss and depression. She lives with her husband Bill, who also has type 2 diabetes, and is her main carer. We have eight ambitions for Dorothy and people like her which are: helping Dorothy to look after herself organising her care better keeping her safe in her home joining-up the team looking after her having one number for her to call for help, advice or support responding rapidly to her at home when she becomes unwell and needs it making sure Dorothy can get home from hospital quickly and safely giving Dorothy, her GP and the people looking after her better access to expert advice and faster access to her test results in the community The following eight slides will explore these further …

ESTHER In Action: Bridge MDT are thrilled to be ESTHER Ambassadors This was the first MDT for Kent and Medway – developed as part of the NHS Vanguard programme (Encompass Multi-Speciality Community Provider)

Thank you Cathy Bellman Kent and Medway STP Local Care Lead Email: Cathy.Bellman@nhs.net Tel: 07721 643583

Anne Tidmarsh- Director Partnerships Adult Social Care and Health (KCC)

Lunch, Networking & Market Place

Graham Gibbens- Cabinet Member for Adult Social Care & Public Health

ESTHER Inspiration Day Graham Gibbens Kent County Council Cabinet Member for Adult Social Care & Public Health

ESTHER Inspiration Day - Closing Designs high impact solutions Creates the workforce of the future Meets the challenges facing Health & Social Care Innovative use of technology especially digital What matters to YOU! Building care based on the individual’s preferences rather that fitting them into our systems Meets the Challenges facing health & social care I hope you have enjoyed the day. The conference has focussed on ‘what matters to ESTHER’ but it is also about what matters to you. Todays event was designed to inspire you, your team and organisation to be passionate about person centred care and quality and I hope this matters as much to you as it does to me. Works with Global Partners Innovative use of technology especially digital Website: designandlearningcentre.com Follow us on Twitter: @KentDLC

Key factors to meet the future demands in health and social care: ESTHER Inspiration Day - Closing Key factors to meet the future demands in health and social care: Prevention – advice, screening etc. Self care – individuals personal responsibility Empowerment – both individuals and staff to be one step ahead and continuously improve Designs high impact solutions Creates the workforce of the future Meets the challenges facing Health & Social Care Innovative use of technology especially digital Meets the Challenges facing health & social care We have a challenge now and in the future to meet demand and maintain quality of our services If we work together we can succeed The ESTHER care philosophy unites us and provides individuals with what they need, when they need it most. Thank you for your participation today. I hope you found the event inspiring. Our ESTHER team look forward to working with you on your plans and ideas for taking the ESTHER care philosophy forward in your organisation Finally, a reminder of contact details on the next slide. Works with Global Partners Innovative use of technology especially digital Website: designandlearningcentre.com Follow us on Twitter: @KentDLC

Further Information & Contact Website: https://designandlearningcentre.com/ Get live Updates as they happen by following us on Twitter: @KentDLC Email: designandlearningcentre@kent.gov.uk Have a safe trip home.