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New Care Models experience and outcomes Pauline Walton & Maxine Davis
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50 vanguards across the country
“One in six people aged 85 or over are living permanently in a Care Home. Yet data suggest that had more active health and rehabilitation support been available, some people discharged from hospital to care homes could have avoided permanent admission.” NHS Five year Forward View, October 2014 50 vanguards across the country 6 focusing on care homes became a vanguard site August 2015 = Won the bid
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Background – The E & N Hertfordshire Picture
“By 2030 the number of older people with care needs is predicted to rise by 61%” “2,000 extra carers needed year on year to meet increase in demand” Rising pressure on care homes: Unplanned use of health services (e.g. GP, 999) Delayed Transfers of Care Staff pressures Poorer resident outcomes
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Care homes – the current picture in East and North Hertfordshire
92 care homes 3,200 beds 3,000 Looking after residents at any one time £49m 2,205 Spent on residents in care homes in 2012/2013
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454 hospital stays of less than one day
£5.76M 2,794 visits to A&E admissions to hospital from care homes 1,744 454 hospital stays of less than one day 23hrs The A&E attendance rate is 0.96 per 100 population in the over 65 age group residing in care homes. This compares to 0.34 A&E attendances per 100 population of the general over 65s population. Pharmacist visits to care homes can reduce reported errors Care home patients on average have 7 prescribed medicines Patients in care homes much more likely to be taken to A&E than those living at home Patients in care homes are often taken to hospital and sent back the same day – disruptive for the patient Care home patients on average have 7 prescribed medicines – medication errors more common in care homes 7 Nationally, on any given day 70% patients experience at least one medication error (Barber ND et al 2009)
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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 “ ” Partnership At its core are the principles of coordinating care around the needs of the individual, and working to proactively address health and social care issues
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If our project is successful we would expect to see:
999 calls A&E attendances Emergency admissions to hospital Short stays in hospital Calls to the out of hours GP service from care homes ‘Delayed transfers of care’ Medication errors and problematic polypharmacy People living healthier lives for longer in care homes Calls to NHS 111 Staff, residents and families reporting feeling satisfied with care Care home staff choosing to stay longer in their jobs People dying in their preferred location
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Multidisciplinary Teams Rapid Response Effective Technology
Confident Staff Upskilling staff to feel more confident about supporting residents’ health & wellbeing Multidisciplinary Teams Support & advice from pharmacists, dieticians, geriatricians, mental health professional, doctors, therapists & nurses Rapid Response A range of services including a frailty vehicle delivering expert care, supported by tams of healthcare professionals, doctors and nurses Effective Technology GP access to patient information when they visit them in their care homes and data analysis Enhanced GP care Targeted support Workforce Tech in Care Homes Early Intervention vehicle Community Rapid Response Hospital Transfer HomeFirst 14 projects Skilled staff Complex Care Framework End of Life ABC training Workforce Work more closely together Medicines Optimisation Aligned GPs Frailty service HomeFirst Be responsive Rapid Response Early Intervention vehicle Red Bag Trusted Assessor Technology Integrated data and analysis using MedeAnalytics Technology in Care Homes Targeted support for care homes Skilled Care Home staff Care Home pharmacist Community linked geriatric team End of Life care
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Learning from others Adoption:
Sutton - Hospital Transfer Protocol (Red bag) Adaption: Airedale - TeleHealth model Wakefield - Alliance contracting Sharing of ideas/lessons learnt: Gateshead – Medicines Optimisation Gateshead – Aligned GPs Sutton - Engagement model Sutton – Champion roles Nottingham – Medicines Optimisation Nottingham - Systm1 in Care Homes Nottingham – Aligned GPs Gateshead Medicines Optimisation Aligned GPs Airedale Hub/TeleHealth Nottingham City Systm1 in Care Homes Aligned GPs Medicines Optimisation Wakefield Alliance contracting Sutton Hospital Transfer Protocol (Red bag) Engagement 2015/16 = Each site develop models 2017 = Standardised services/models across the CH6 East & North Herts
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Care Home Pharmacy Team
Developments Tech Blood pressure measurements
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Medicines Optimisation overview
“ A person-centred approach to safe and effective medicines use, to ensure people obtain the best possible outcomes from their medicines.” Monday to Friday 9am to 5pm 1. Identify Care Home 2.Arrange access to care home and aligned GP practice/s 3. Liaise with practice to gain access to system. 4. Medication Review 5. Systems and processes 6. MDT meeting 7. Follow up Expert deep dive into residents’ medication Recommendations made to care home’s aligned GP. Decisions actioned. Individual patient Medication Reviews with access to patient records & care plans and administration records Support with Medicines Management Close links between GP, care home, community pharmacy Support to care home staff Links with quality & compliance teams Staff development Ad hoc training We are able to use systmOne to access and drill down through notes to identify why patients have been originally prescribed certain medicines Eg PPIs for gastro protection although NSAIDs stopped Reducing anticholinergic burden Benefits: Prompt action Partnership working Reduced duplication Secure Improved safety Improved health outcomes Reduction in costs and waste Adhoc training opportunities Best practice shared Implementation of guidance Support with CQC preparation and action plans
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Medicines Optimisation more details…
For each patient look out for: Monitoring Inherited prescribing Any medicines with no clear indication Documents e.g. Mental health reviews Identify how often medicines are requested/ repeated and any PRN medicines Any resident with dementia is READ coded correctly Identify if patient is taking ONS and review against local guidance / MUST score Collate all information from: Recent CQC reports Quality team to identify common medicines related issues and themes that have resulted in hospital admissions Community pharmacist to identify medicines system related issues Patients with concerns: Recent hospital discharge/new admissions Frequent fliers, polypharmacy High risk medication Poor medication adherence Multiple co-morbidities
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Medicine Optimisation Early Intervention Vehicle
Impact so far Complex Care training Medicine Optimisation Since April 2015 165 champions trained 26 Care Homes visited so far: 2,910 recommendations Since Dec 2015 Patients reviewed 947 8,720 Medicines reviewed 37% care homes received training Early Intervention Vehicle Since May 2016 76 antipsychotics reviewed with GP …of which 70% were kept in the community 708 visits …of which 1,070 medicines stopped …of which 218 linked to increase in falls Impartial Assessor Since Aug 2016 Direct drug cost reductions £161,987 p.a. (£181/patient) 178 …of which 16 stopped referrals 120 Saved bed days Working days 69 Potentially saved hospital admission cost (using Rio tool) £334,240 Data as of 9th December 2016
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Systems and Process - RiO scoring
Developed by NHS Croydon, based on the Hospital Avoidance Scale within the RiO system and adapted to provide a simplified health intervention scoring tool. A qualitative assessment is made of the potential impact of each intervention allowing the assignment of a value of likelihood with regard to the prospect of the intervention preventing a hospital admission. Definition Recommended that interventions are peer reviewed to ensure consistency of approach. Reviewed within our own pharmacy team and externally with HVCCG and HCT pharmacists. Used in several areas across the country and has been incorporated into the RPS document Supporting use of pharmacists in care homes. Average cost of hospital stay for this pt group is £2,600 Scoring Level 1 Lifestyle advice Compliance aid to remove medication from a blister Unnecessary food supplement stopped Level 2 Long –term steroids; bisphosphonate started Spacer device added for patient with asthma with poor inhaler technique Crushing of modified release medication stopped. Level 3 Insulin instructions changed; resident was being given novorapid despite low blood glucose levels Elderly patient prescribed SSRI and aspirin, gastro protection started Diazepam rectal added for patient with poorly controlled epilepsy Peer review = We also plan to ask for GPs to be involved in the peer review process. Concerns: Open discussion – what are people’s experiences… Subjective Not been academically reviewed/ validated.
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Enablers Based in care homes One Care Home one GP practice
IT – solutions to viewing notes there and then Effective GP engagement through face to face in situ discussions Previous evidenced pilot work Vanguard –integrated working Integrated working with HCPA – HCC Interface geriatrician Community Services Mental Health Trust LPC
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Ambitions for the future
Expanding the scheme to cover more care homes Develop pharmacist independent prescribers Dietetic Support More written support materials AKI training for care home staff Antibiotic and treatment of UTI training Improved templates within GP clinical systems for med. Reviews Linking with GP based practice pharmacists to cascade and develop workforce Involvement in providing CPPE training Community Pharmacy workforce development. Spread across STP. Apply programme principles to home care services for our vulnerable housebound residents Evaluate outcomes more systematically
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Care home Pharmacists Red Bag Find out more…
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Thank you for listening. Questions?
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