2. SWCCG Care Homes Project 2013- Current and the Future Dr Maggie Keeble

3. What has been achieved Care Home Pilot Project Nov 2012- March 2014 5 Care Home Practitioners 2 Worcester City and Droitwich 1 Evesham Broadway and Bredon 2 Malvern Upton (Tenbury) GP LES

4. What has been achieved 1875 Care Home beds ( Excluding Registered Learning Disability Homes) 24 Nursing Homes (1047 beds) 37 Residential Homes (828 beds) 28 GP Practices

5. What has been achieved End of March 2014 2100 Clinical Management Plans completed 778 Prescriptions issued 725 DNACPR Forms 437 Joint Visits

6. What has been achieved Project Evaluation 11 months from Nov 12 to September 13 15 % reduction in admissions from Care Homes in South Worcestershire

7. What has been achieved November – February 2012/13 vs November - February 2013/14 23.1% reduction in A&E attendances from Care Homes 26.5% fewer admissions Total reduction in admissions - 212 Total savings £700,000

8. Care Management Plans

9. Care Management Plan Incorporates discussion about: EOL wishes DNACRP Category of Care Choice

10. In Development Worcester City Pilot: One GP practice to One care Home Liaising with colleagues Liaising with care homes Letters to care home managers Letters and FAQs to residents/relatives Proactive care – reduction in visits

11. In Development New patient registration forms with Read Codes Weekly reporting sheets E-CAP - escalation plans Advance Care Planning Decisions Tool Education around Mental Capacity Issues in Care Homes Use of Greensleeves COMPASS

12. In Development

13. Weekly reporting sheets

14. E-CAP

15. Advance Care Planning Decision Tool

16. Mental Capacity Issues surrounding Care Planning Has resident got capacity to make decisions around DNACPR and EOL care? Mental Capacity Assessment Best Interest Decisions DoLS Safeguarding issues Power of Attorney decisions

17. Greensleeves

18. Aid to communication across the interfaces of care Will be coming out for all patients on Amber Care bundle Will be used in care homes for all patients if transferred to ensure DNACPR forms and Advance Care Planning document follows patients

19. Comprehensive Assessment Use of CGA as basis for developing shared documentation for across all Health and Social Care agencies Liaise with EMIS to develop a Comprehensive Assessment template with information available to share Comprehensive Assessment and Care Plan documentation kept in Care home/own home – follows the patient in and out of hospital along with DNACPR form Use of Greensleeves wallet

20. COMPASS Comprehensive Assessment ‘a navigational tool to enable orientation and determine the direction of travel’ To be compiled by all To be used by all To be shared with all Reduction in repetition Improved communication Creates a baseline of functioning prior to acute admissions

21. What next? Increased numbers of Care Home practitioners Roll out of One Practice to One Care Home to all localities Weekly reporting sheet in every home Proactive approach to reduce visits ANPs managing minor illness – rashes simple infections

22. What next? Pharmacy support for medication reviews and reduction in wasteful prescribing Increased support from ECT – Admission Avoidance, IV antibiotics, SALT, SC infusion of fluids etc Increased use of ECAP to prevent inappropriate transfers and admissions Consultant/GPwSI support with complex or EOL cases Development of COMPASS

23. Its up to you…..