Suffolk Care Homes An Integrated Approach Lee Taylor – Transformation Lead West Suffolk Clinical Commissioning Group 16 October 2014

Context The Health and Wellbeing Board strategic outcomes Suffolk residents have access to a healthy environment and take responsibility for their health and wellbeing Older people in Suffolk have a good quality of life CCG priorities particularly relevant to the care homes landscape Improve the health and care of older people Improve health and wellbeing through partnership working Demonstrate excellence in patient experience

Objectives to support the health and well-being of Suffolk residents Aim to improve quality and safety standards across care homes in Suffolk and create a network of support through a whole system approach To promote integrated delivery systems between Health & Social care Ensure that an integrated approach is employed to: Improve clinical care Reduce admissions to hospital Reduce call outs to OOH Reduce ambulance call outs reduce average length of acute bed stay increase number of people reporting positive recovery and reablement improve the ‘advance care planning’ process – increase in Yellow Folder issue Work with care homes with the highest admissions to West Suffolk Foundation Trust, Ipswich Hospital Trust & Cambridge University Hospital

Key Facts 137 Care homes across East and West Suffolk 2,738 A & E emergency attendances 2013/14 represents 5% overall activity across east and west Suffolk Year to date (14/15) 4.78% overall activity across west and east Suffolk 1/6th ambulance call outs are to care homes Top conditions for unplanned admissions from care homes UTIs Lower Respiratory Tract Infections Pneumonia Tendency to fall Fractured Neck of Femur

Proactive Care Services UTI Developing prevention and support guidelines for care homes Work on-going to understand blocked catheter challenge Admission Prevention/COPD/Pulmonary Rehab teams Admission Prevention Service – COPD team enhancing their access and availability Increased general practice linkage Enhanced ambulance service access Falls assessment and management Increased assessment opportunities between General Practice, Suffolk Community Healthcare and East of England Ambulance Service NHS Trust West Suffolk Fracture Liaison Service MDT approach supporting General Practice and hospital Actively follow up fracture patients ensuring adequate bone health medication Lifestyle advice

Suffolk Care Homes Group Multi-organisational group with the overarching aim to support the health sector Care homes, CCG, Adult Community Services, Acute Trust, Pharmacist, Ambulance Trust, Primary Care representation Operational group to support activity across Suffolk specifically in relation to care homes Linked into a wide integrated governance framework across West and East Suffolk

East Suffolk West Suffolk Ipswich and East Suffolk System Forum West Suffolk System forum Ipswich and East Suffolk Urgent Care System Group Suffolk End of Life Education Group Integrated Care Steering Group Integrated Care Workstream Integrated Care Operational Forum Care Homes Group Care Homes Clinical Support Manager (WSFT) Quality Functions Operational Pathways Patient/customer experience Visits/ inspections Training opportunities/workforce Data dashboard Enhanced services Assessment tools Pathways mapping

Quality Functions Develop fluid working practices between health and social care to enhance knowledge around inspections and visits Development of a combined self-assessment tool to assist care homes Develop integrated training opportunities for care providers Wider Suffolk workforce development programmes Falls awareness training Review patient / customer experience for ‘360 review’ Development of a Statement of Intent - a visual commitment to integrated work by health, social care and care homes

Operational Pathways Development of a data dashboard Assist the sector by understanding on-going challenges Identify training opportunities for all Linking information available from Acute Trusts, CCGs and SCC Proactive approach with primary care to support patients in care homes and establishing links to agencies such as ambulance to ensure our patients receive the right care, in the right place, at the right time Multi-disciplinary approach to support an individual patient Proactive Care Weekly ward rounds – GP and sessional pharmacist Medication reviews Falls assessment Vaccinations Improved patient experience Patient shared care plans to ensure comprehensive assessment

Operational Pathways Establish pathway efficiencies and blockages through close review of planned care, urgent care and discharge pathway interactions Understand most common areas of concern Build resolution in consultation with the sector Discharge workshop – early outcomes Review discharge processes from the acute Review of medication TTO processes Work towards a proactive discharge process Acute Trusts and care homes to be clearer on expectations Increase confidence levels to improve pathways and patient outcomes Care Homes Clinical Support Manager Based in the West Suffolk Hospital Link across care homes, community health services and the acute

Lee Taylor – Transformation Lead West Suffolk Clinical Commissioning Group Lee.A.Taylor@westsuffolkccg.nhs.uk