1. East and North Hertfordshire East and North Hertfordshire: Care Home Improvement vanguard Claire Jackson, Clinical Quality Manager, ENHCCG Michelle Airey, Recruitment & Logistics Manager, HCPA

2. 2 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”

3. 3 Patient presents with Complex Characteristics Complex Care Premium Referral Accredited Care Home Top up Payment Quality care for complex patients

4. East and North Hertfordshire CCP Team

5. East and North Hertfordshire Inputs Expectation Setting Session 5 x Qualified Advanced Champions – Training AET L3 Subject Specific Qualification Preparing for a Coaching Role L4 1 x Mentored Engagement Advanced Champion – Training Engagement Practice in a Care Setting L3 Individual Exercise Plans 1 x Manager - Training 6 months of Beyond the Armchair Pre- Evaluation Preparing CCP Team Support Meeting x 2 per home minimum

6. East and North Hertfordshire Outputs 5 x Qualified Advanced Champions Cascading Knowledge and Skills to staff through mentoring, coaching and training 1 x Mentored Engagement Advanced Champion mentoring Knowledge and Skills to staff 1 x Manager Setting Strategies Reviewed Activity Plans and Recording Procedures for Engagement Individualised Falls Risk Report Engagement Lead delivering 1:1 tailored exercises IFS Report and Action Plan Post Evaluation Action Plans for each pathway and overall Monthly Data Collection Report Action Planning for each pathway Certificates Badges & Marketing Materials Display Board

7. Care homes in the wider health system 7 Key Milestones for delivery The key milestones for delivery will be: 1.Confident Staff Homes receive Complex Care training and receive top-up premium All homes receive enhanced dementia and End of Life training 2.Multi-Disciplinary Team Enhanced Primary Care support implemented Care Homes Medicines management team in place Interface geriatrician team in place covering all homes Homefirst enhanced community teams in place Specialist end of life nursing team in place 3.Rapid Response Community rapid response teams (Homefirst) in place Rapid response vehicles operational 4.Information, data and technology Primary care data fed into MedeAnalytics to deliver Care Home performance dashboard Telemedicine rolled-out Primary care data extracted and fed into risk stratification model

8. CCP Case Study While Burleigh House already had strong links with local GP surgeries and Lister Hospital the introduction of dedicated GPs for each care home and regular visits from community pharmacists to review patients’ medications is proving very worthwhile. “Training gained through the Complex Care Premium allows us to act more effectively as a preventative source. With their new training staff can identify potential risks earlier and flag them up with doctors and prevent residents’ conditions worsening.” Ian, 61, has been a resident at Burleigh House for less than a year. He suffers from Epilepsy and has complex care needs following a fall at home. He initially came to Burleigh House for respite care, but liked it so much he asked if he could stay. Staff are keeping on top of his medication and are able to support him when he has a crisis, rather than always calling an ambulance to take him to hospital. Both Peter and Mihir agree that the care homes ‘vanguard’ project fits with the home’s ethos of managing the health and wellbeing of their residents to give them a better quality of life. 8

9. East and North Hertfordshire Outcomes CCP Team Meeting & Case Notes Weekly/Monthly Reviewed Staff Training Plan reflecting CCP Training Stronger senior team Lower Hospital Admissions Lower Ambulance Call outs Improved Service User Experience, personalised, focussed on wellbeing Improved Family Communication/Involvement Improved communication with clinical professionals and better management of health issues Fewer behaviours that may challenge – less reliant on CAT and less anti-psychotic medication Better Weight Management & Hydration & Reduction in Supplements Fewer Falls, improved stamina, increased flexibility, improved muscle strength Prevention and/or better management of wounds End of Life audits Confident staff teams Service Users being managed under ‘Best Ability to Function’ guidelines Good/Outstanding Monitoring Reports Continue onto CC-CPDF

10. As a result of our project we would expect to see:

11. Progress to Date 11 Complex Care Premium developed and established Training delivered and commenced to 20 homes (12 in E&N CCG area) – collecting data from Oct 15 10 further care homes identified for phase 2 Complex Care Foundation and application to home care? Project Group established, a variety of initiatives underway: Care home pathways review Medicines optimisation Frailty Vehicle Enhanced primary care support End of life care Telecare