Nursing & Care Homes Support – East Sussex Sophie Clark, Older Peoples Strategic Commissioner, ESCC ASC Kay Muir, Programme Lead, End of Life Care, NHS East Sussex

Services Supporting Nursing & Care Homes Dementia Support Team End of Life Care Team E. Sussex Care & Nursing Homes team Medicines Management Support Dietician Adult Social Care Quality Monitoring Team

Work already underway End of life care and dementia teams fully established Care & nursing home support team recently in place Large overlap in ‘priority homes’ lists between services, with some differences reflecting profile of need for specialist services e.g. dementia care

Working together Services need coordination to ensure maximum impact, avoid duplication etc. Steering group established to: –Agree priorities and overall workplan –Record activity done with each home –Share information and develop a holistic package of support for each home

Working model Initial visit to home by one or other team to assess support needs Agree improvement plan with home Coordinated approach between teams to cover nursing & care competencies, falls prevention, medicines, end of life care, dementia etc as needed Initial focus on homes in highest need

Team Composition TeamProviderCompositionContacts End of Life CareSt Michaels Hospice St Wilfrid Hospice Specialist palliative care nurse Consultant input as required Trainers Jo Barnes Carolyn Skilton Kay Muir (End of Life Care – PCT) Dementia TeamSussex Partnership Trust 0.5 x Psychiatrist 0.5 x Pharmacist 3 x Community Psychiatric nurse 1 x Occupational Therapist Stephanie Giles Nigel Blake-Hussey (PCT / ESCC) East Sussex Care & Nursing Home Support Team ESHT1 x Physiotherapist 1 x Occupational Therapist 1 x Dietician 0.3 x pharmacist 1 x B3 admin 1 x Community Matron – TBA 1 x B6 Physio - TBA Michelle Connelle Adult Social CareEast Sussex County Council Safeguarding teamsPaul Maynard Sophie Clark (Older People’s Commissioning) Quality Monitoring TeamEast Sussex County Council Contracting staffMalcolm Price

What else is needed? Confirm availability of Community Matron resource (current nursing skills gap) Develop mechanism to accept referrals From A&E and hospital staff From GPs Develop links to CCGs Getting access to local knowledge Medical cover if needed Following up recommendations e.g. drug changes Help get access to and ‘performance manage’ homes

Outputs to follow Combined quarterly reports from all teams –Activity, impact on quality, safety, costs Outcome data on hospital admissions, 999 calls, fractures etc Feedback from homes, patients, stakeholders Evaluate impact and develop business case for future funding (Feb 12)

Aim of EOLC provision To pump prime services for 1 year to support Care Home staff to provide good quality EOLC to meet the resident and family needs. In addition to significantly contribute to: the whole system reduction in End of Life Care (EOLC) emergency hospital admissions and deaths

End of Life Care Provision for the Care Home Support Team EOLC staff support: Eastbourne and surrounding area - St Wilfrids Hospice Hastings and Rother area - St Michaels Approach taken: Use of EOLC emergency admission data and urgent care data on Care Home resident attendances at hospital Multi-disciplinary approach with support Hospice Medics and training department, GP liaison, ESCC Quality Monitoring team, wider Care Home project linked to Urgent Care Initial contact made to the senior management of the care home by the SPC nurse combined with a joint letter of support to Care Home from the PCT and ASC

Meeting national EOLC competencies and standards ESCC Care Home Contract “That the Service Provider and their staff should ensure they are familiar with the principles and best practice guidance set out within the national End of Life Care and East Sussex End of Life Care Strategies, and apply the principles and good practice of the Gold Standards Framework for Palliative Care.” “The Service Provider should ensure that staff have access to and are encouraged and supported to use nationally recognised end of life care tools such as: Advance Care Planning Preferred Priorities of Care Liverpool Care Pathway for the last few weeks/days of life NHS South East Coast Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) principles”

EOLC project reporting Baseline audit: After Death Analysis and Routes to Success Care Home questionnaire 2.Documentation of managerial and staff commitment to adopt national standards and competencies 3.Documentation recording what the status is of the Care Home provision along each stage of the EOLC pathway at baseline, interim report and final report using the Routes to Success template 4.To have a written action plan with clear priorities to target in relation to quality and emergency admission avoidance for each home.

Reporting Training record by subject and uptake for each care home involved with. 7.Recording of emergency admissions to hospital each month and reason why and if these could have been prevented 8.Ongoing ADA with subsequent deaths in the home during the pilot period, actions required to improve the quality of care identified and shared with Care Home manager and staff 9.Proactive actions taken to reduce avoidable admissions as a result of the project 10.Interim report being presented to the PCT Commissioning Clinical Executive view to extend project by 1 year funding permitted