1. East and North Hertfordshire: Care Home Improvement vanguard Anna Makepeace, Project Manager

2. “By 2030 the number of older people with care needs is predicted to rise by 61%” “ 5% of all emergency hospital admissions in Hertfordshire involve patients resident in care homes ” Rising pressure on care homes: Unplanned use of health services (e.g. GP, 999) Delayed Transfers of Care Staff pressures Poorer resident outcomes Hertfordshire Background

3. East North Herts Demographic background

4. Our Vision To deliver an enhanced model of health and social care to support frail elderly patients, and those with multiple complex long term conditions in the community in a planned, proactive and preventative way “ ”

5. Confident staff in Care Homes Multi-disciplinary Team Rapid Response Effective Technology 1. Complex Care Framework 2. End of Life ABC training 3.Workforce 1. Complex Care Framework 2. End of Life ABC training 3.Workforce 8. Rapid Response 9.Early Intervention vehicle 10. Red Bag 11. Trusted Assessor 8. Rapid Response 9.Early Intervention vehicle 10. Red Bag 11. Trusted Assessor 12. Integrated data and analysis using MedeAnalytics 13. Technology in Care Homes 14. Targeted support for care homes 12. Integrated data and analysis using MedeAnalytics 13. Technology in Care Homes 14. Targeted support for care homes 4. Medicines Optimisation 5.Aligned GPs 6. Frailty service 7. HomeFirst 4. Medicines Optimisation 5.Aligned GPs 6. Frailty service 7. HomeFirst Programme Overview

6. Independent assessor to facilitate discharges from Lister hospital to residential and nursing homes 6 days a week We want to: Facilitate the discharge of patients into a care homes to avoid unnecessary delays Increase the bed flow and status Reduce mis-communication between the hospital and Care Home Reduce the need for Practitioners needing to come into the hospital to assess, freeing up time and resources Trusted Assessor

7. Key partners

8. Patient medically fit for discharge Care Home receives assessment, agrees it Trusted Assessor completes assessment Trusted Assessor completes assessment Patient transferred back into the Care Home Discharge process

9. 1.Work within the hospital discharge team and social services based at Lister Hospital to act on behalf of social care providers to support and facilitate timely and safe discharges from hospital to care settings 2.Work with agreed assessment formats (standardised across county). 3.Undertake assessments and re-assessments on behalf of care providers in Hertfordshire 4.Work in partnership with care settings and the hospital to find solutions to issues arise that delay discharge 5.Work with relevant ICT systems, including social care and NHS. 6.Provide full evaluation for reporting purposes on assessments, information dissemination, discharges, bed days saved and write monitoring reports as required. Roles and Responsibilities

10. “Trust with the care homes is key to the project” The Assessors are employed by the Care Association (HCPA) and works on behalf of the homes It is important that care homes can truly trust the assessor and see her as independent. This is the message we give to the homes The Assessor has experience of working in the health and social care sector as well as working within the hospital The assessor will act to champion homes and highlight needs/challenges which may not have been picked up in the past and acts in the homes best interest Working with the Care Homes

11. Ongoing Recruitment to second post. Service become 6 days service November 3 month evaluation Feb 6 month evaluation Roadmap On track Progress 2nd August Trusted Assessor Go Live

12. ChallengesHow are we tackling this? Access to ICT systems, informationNHS honorary contract. Working closely to partners to understand the different systems. Recruitment to post (not on NHS terms and conditons) Shared on partner job sites. Care Home buy inHCPA employ individual = ‘independent’ Engagement with care homes Continuous learning and best practice Information GovernanceNHS honorary contract. Signed up to organisation’s policies. Lots of different ways for referral pointsWorking closely with discharge team & social services to map them. Based in both offices to help reduce gap. Challenges

13. Evaluation Proposed metrics are as follows: % of days saved as result of the Trusted Assessor % of discharges using the Trusted Assessor % of re-admittances to hospital % of homes using process Location of referrals Number of assessments completed Time from referral/ assessment to actual discharge Average time to complete each assessment Compliments/ Complaints