Joint working with Care Homes Update Zoe Robinson 19 th May, 15

Project Summary Improve joint working between homes and community services  building preventative capacity within homes  reviewing barriers within specific pathways  enabling a more proactive approach to managing long term conditions and improved community responses. Target  At end of Q4 show a 10% reduction in unnecessary ambulance conveyances to A&E from Nursing and Residential Homes by 10% across all Sutton and Merton homes.  7%

Challenges GPs shut for longer than normal over Christmas due to overlapping weekends and bank holidays Winter bugs were rife Staff changes in the homes Residential care homes managing more EOL pathways Sepsis

Successes Homes were very good at engaging and open to working in partnership Joint working across Community Services (including Falls, CPAT, EOLT, Nursing), CCG, LAS, St Helier and Council Responsive training Follow up resources Forum Mary

Community Home Liaison Nurse - Mary Visited all homes to co-ordinate training and build stronger links with community teams working with the homes. Improve pathways into, and joint working with homes. Identify and co-ordinate training for home staff. Improve transition points for residents by working with LAS, inpatient services and homes. Proactively identify management strategies for high risk residents, via ward rounds and dedicated home visits. Reviewing data with LAS to focus interventions with homes.

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