1. Unplanned Admissions DES : The Process Dr Maggie Keeble & Clare Gibbs

2. Identifying your 2% 2% of over 18s most vulnerable to unplanned admission + children with chronic disease Unplanned admission more common in older people and people with chronic disease and multiple co-morbidity Logical therefore to look at Care Home population and Palliative Care registers first

3. Finding your 2% The Rest Care Home Population Palliative Care Register

4. Numbers

6. ‘Coding, Coding,Coding’ First make sure you are coding your care home residents (In a care home) In a nursing home - 13F61 In a residential home- 13FK

7. GMS Global Sum payments THE GLOBAL SUM ALLOCATION FORMULA Introduction B.1 The global sum will be allocated using the Global Sum Allocation Formula. This formula aims to ensure that resources reflect more accurately the contractor’s workload and the unavoidable costs of delivering high quality care to the local population. B.2 The formula consists of the following components— (a) an adjustment for the age and sex structure of the population; (b) an adjustment for the additional needs of the population, relating to morbidity and mortality; (c) an adjustment for list turnover; (d) a nursing and residential homes index; and (e) adjustments for the unavoidable costs of delivering services to the population, including a Market Forces Factor and rurality index

8. GMS Global Sum Payments Nursing and Residential Homes B.5 Patients in nursing and residential homes generate more workload than patients with otherwise similar characteristics who are not in homes. A factor of 1.43 is applied in respect of each patient in a nursing or residential home.

9. Palliative Care Registers Very different ways of compiling register Some will include All their care home population Some will only include those at the very end of their lives Each practice needs to consider how their palliative care register with dovetail into their 2% population

11. Children with chronic diseases No guidance Consider children with recent multiple admissions – from Ventris Children with life limiting conditions Liaise with Health visitors to compile list

12. Tools for identifying your 2% Requirement: Establish case management register for 2% of practice population aged 18 >. In addition, children with complex health and care needs Based on CPR as at 1st April 2014 (Quarter one) Tools: Use the ACG tool to identify 2% - Guidance produced by Dr Phil Thompson available in your pack. NHS numbers can be imported from the ACG tool into EMIS search and reports, and additional searches developed to help manage the list, generate letters etc. **CAUTION** data produced via the ACG tool is based on February extract, therefore practice will need to check for patients that are deceased/de-registered before including them on the register. Guidance on how to build the searches in EMIS Web will be available by 30th May 2014, along with instructions on how to remove duplicates from an excel sheet e.g. those living in a care home, and those on ACG report. Super User support available if required.

13. Maintaining the list As patients die or if their condition is much improved they will come off the risk list - There is a requirement to maintain at 2% level during the year. Some will be picked up as they go onto Palliative Care register - ZV57C, others as they move to a care home Need mechanism to ensure that when an already registered patient moves to a care home that you code appropriately that they are in a home – to trigger GMS payment but also to highlight need for Comprehensive Assessment and Care planning Then you need to run your searches again….

14. Maintaining the list Requirement: Maintaining the list at a minimum of 2%, whilst ensuring the number of patients on the register accurately reflects the 2% of the practice population Tools: For quarters two-four, use the Ventris combined tool to identify and top up the 2% ( Functionality will be available in approximately 8 weeks) Guidance and support will be made available to assist practices with this process. Action: - Each practice to activate electronic consent via EMIS Web. - Each practice to sign Data Processing Agreement to enable Arden CSU to process data via Ventris. Quarter 1Based on registered population 1 st April 2014 Quarter 2Based on registered population 1 st July 2014 Quarter 3Based on registered population 1 st October 2014 Quarter 4Based on registered population 1 st January 2015

15. Read codes DescriptionCodeWhen to use Admission avoidance care started8CV4.to include patients on the case management register Admission avoidance care ended8CT2.To take patients off the case management register Informing patient of named accountable GP67DJ.Also applicable to named GP for patients 75 & above Admission avoidance care plan agreed8CSB.Once plan has been agreed - REMEMBER to code those patients that already have a care plan, e.g. Those living in a Care home, and those on the Palliative care register Admission avoidance care plan declined8lAe1For those patients that decline a care plan Review of admission avoidance care plan8CMG3Use each time the care plan is reviewed Emergency hospital admission8H2..%Use to identify those patients admitted to hospital At risk of emergency hospital admission 13Zu. Use to identify patients who you may wish to consider inclusion on their register Multi-professional risk assessment declined9Oh5.* Use when a patient decides to opt out of having their data shared for risk stratification * There should be fair processing notices in your practice and on your website to inform patients that their data is used for risk stratification purposes

16. Templates Templates taken from the Avoiding Unplanned Admission Enhanced Service guidance: http://www.england.nhs.uk/ourwork/commissioning/gp-contract/ Letter and leaflets template needed to inform patients (adults and children) enrolled in to the Enhanced service available National Care plan template There is a requirement to Read code the initial patient letter using 8CV4. admission avoidance care started These have been adapted in EMIS Web to contain pre -populated merge fields, are printable, and will be disseminated to practices shortly.

17. Reviewing and improving the hospital discharge process The practice will ensure that when a patient on the register is discharged from hospital attempts are made to contact them by an appropriate member of the team ….in a timely manner…..normally within 3 days of discharge notification being received….

18. Reviewing and improving the hospital discharge process The practice is required to regularly review emergency admissions and A&E attendances of their patients from nursing and residential homes.

19. Follow up after all admissions Read Codes Emergency Hospital Admission 8H2..% Monitoring of weekly emails from Acute – ‘RhapsodyLive Worcester’ – to see who is in Use relatives/care home to inform when discharged Weekly reporting sheet from Care Homes

20. Weekly reporting sheet

21. Document Template

29. The Future National Template – basic information – compiled in Primary Care Shared with other agencies Sharing with NOK/spokesperson WHAT WHACT WCC Voluntary agencies Need to get consent to share as Assessment being done Flags on other systems to alert to ‘At risk of admission’ status

30. The future Comprehensive Assessment and Care Plan 5 domains of Comprehensive Geriatric Assessment Medical/Mental/Functional/Social/Environme ntal Recognised by all agencies – shared by all agencies – compiled by all Provides a baseline assessment for those who are admitted

31. ‘COMPASS’ COMPrehensive ASSessment COMPASS + - incorporating the Care Planning process Developing COMPASS EMIS template Putting EMIS and hence General Practice at the centre of this process – supported by other agencies – in compiling information Community clusters with MDT model

32. Worth remembering…

33. Co-operation can reduce workload