1. Sovereign Harbour Yacht Club 3 Harbour Quay, Eastbourne 18.09.12 Older People Residential & Nursing Provider Forum

2. Ann Barrett Occupational Therapist Team Lead - East Sussex Care & Nursing Home Support Services Julie Sands Advanced Community Nurse Practitioner Robin Warshafsky GP, Urgent Care Lead, High Weald CCG Associate Medical Director, South East Health

3. Ann Barrett ESCANS (East Sussex Care & Nursing Home Support Service) Julie Sands Presentation to raise awareness of Community Matron Role and recognise the signs of deterioration in residents Admission avoidance and a reduction in GP visits to a local care home – is it achievable? Robin Warshafsky Guidance on obtaining a doctor’s advice out of hours Care Home referral form to out of hours

4. Collaboration between NHS resourced clinical support and Care Home Sector PURPOSE Improve quality of care to residents by: Offering education & tools to care home staff for better care & decision making Offering to review care of residents to ensure meeting goals of management plans Offering to assist in review of medication management Offering to assist in end of life care goals and advance care planning WHY? Maintaining high quality care for care home residents is everyone’s business: Residents, Families, NHS, Care Home Sector, Society No one group can achieve on their own Becoming larger issue, see demographics, next slides Excellent way to promote the care you offer to prospective clients / residents and their family members

5. 2011 CENSUS 65+ England & Wales 16.4 South East17.2 East Sussex22.7 Eastbourne22.4 Hastings16.9 Lewes22.8 Rother28.4 Wealden22.8 SECULAR TREND 65+ 201020152020202520302035 England16.518.018.719.921.422.9 South-East17.219.220.421.823.925.6 East Sussex23.526.027.429.231.934.2 Eastbourne23.324.926.328.030.432.4 Hastings17.619.721.122.624.927.0 Lewes23.725.726.928.831.333.5 Rother28.531.433.135.038.040.5 Wealden23.426.9 30.733.535.8 EAST SUSSEX 85+ SECULAR TREND 201120152020202520302035 19, 90023, 60025, 60030, 00036, 60046, 600

6. 17% increase in deaths from 2012 40% of deaths in hospital could have occurred elsewhere East Sussex: hospital 49.0% 60% people do not die where they choose East Sussex: home 17.6% hospice 6.8% care home 24.1% 75% deaths are from non-cancer conditions 85% of deaths occur in people over 65 £19,000 non cancer, £14,000 cancer - average cost/patient in final year of life www.endoflifecare-intelligence.org.uk www.goldstandardsframework.org.uk

7. Maintain & enhance the quality of health care for the residents of Care Homes in association with pharmacy and nursing staff providing health care cover to each Home, so offering consistency, efficiency and a higher quality of service. Expectation: this will offer alternatives to admissions to acute hospitals and help make more informed decisions regarding use of Out of Hours services by Care Home staff. Evidence  patients in Care Homes have higher needs than other patients for essential medical cover  medical needs are complex and changeable Require visits to Care Home, frequent & multiple prescribing interventions & they have a higher than average use of Out of Hours Services. from generic Care Home Enhanced Service Specification document

8. “We looked at how to take a collaborative approach to support care home staff with a package of regular training, a care plan for patients, and a nurse specialist who could work alongside them and support them with advice and guidance.” Gateshead Clinical Commissioning Group

9. WALES 2008-2009 Enhanced Service for Care Homes Provide patients with 6 monthly medication reviews thus ensuring that prescribing is appropriate for the patient minimising risk to the patient Build effective communication links between Primary Health Care Teams & nursing and residential care staff Ensure, where appropriate, that patients have the opportunity to record their EoLC plans and to ensure such plans are available when required Reduce inappropriate admissions Improve this vulnerable group’s overall health by providing a more holistic service

10. Barking & Dagenham 2008 Enhanced Care Home Service A dedicated weekly session per nursing home including visits; A more comprehensive assessment of all new admissions; A yearly assessment of all residents; Demonstrably increased availability via telephone for medical advice and triage Lead responsibility for assigning appropriate aspects of service provision to other care professionals; e.g. medicine management and pharmacist support or preventative work carried out by nursing or health care assistants

11. Better acquisition, documentation & sharing of essential information about the resident to inform decisions “The assessment information will be recorded in the patient’s record and the care plan will be held at the care home to assist in the management of the patient and be available to practitioners out of hours.” “work with nursing home staff and patients, where the clinician feels it is appropriate, to develop end of life care plans with patients and their relatives. Such plans will be held both in the patient’s notes and by the care home staff and must be available when required. These plans will be available at the care home and can be accessed out of hours along with the care plan.”

12. In Words Resident ‘ ”I only see him once a week when he comes to do the rounds – he is a very nice young man and he is very good. He understands you and wants the best for you and listens to what you say. I’ve been here a year and seen another student doctor but have had no problems with either. Sometimes he is on holiday but it doesn’t matter. He always orders the prescriptions monthly or something and they are sent over automatically – he is very [conscientious].” Care Home Manager “Two years before, a number of different GPs visited the home and referral processes took longer. Now the whole service has been brought together and it is quicker. It really has been amazing for us: good for relationships between GPs and next of kin or friends, and has cut down referrals to hospital. Having someone come in and refer to clients personally has made a difference.” Briggs, D & Bright, L. Reducing hospital admissions from care homes: considering the role of a local enhanced service from GPs Working with Older People Volume 15 Issue 1 March 2011

13. By Numbers “aims … were achieved   43% in emergency admissions  45% reduction in deaths in hospital “Improved anticipatory planning and increased medical and nursing support for patients and staff in residential homes may help to further reduce emergency admissions and deaths in hospital in future.” Evans, G. Factors influencing emergency hospital admissions from nursing and residential homes: positive results from a practice-based audit. J Eval Clin Pract 2011 Dec; 17(6) :1045-9.

14. Julie Sands Advanced Community Nurse Practitioner (ANCP) (Formerly Community Matron, CM)

15. 74yr old lady H/O arthritis Hypertension “Breathlessness”! Recent bereavement Ex smoker 2 weeks! Recurrent chest infections

16. BP 180/80 P68 reg R19 sats 93% Bilateral ankle oedema to calf. BMI 35 PF diary ranged from 150 – 220 Post ausc – good air entry with fine crackles to left mid, lower and aux zones, right lower and aux zones. Ant ausc – unable to due to size Poor mobility due to arthritic pain Random BM 13.3mmols

17. Ask PN for spirometry Check bloods for Hbalc Discuss meds with GP for BP, pain and chest following spirometry Advice re diet

18. Spirometry - FEV in 1 sec, 0.82 litres.min 58% - FVC 1.42 litres/min 81% = mild COPD o HbA1c – IFCC standardised 55 mmols/mol (7.2%)

19. Introduce Seretide inhaler Introduce tiotropium inhaler Introduce ACE (Ramipril) Increase/change dieuretics Monitor diet for diabetic control and weight loss Increase analgeisa for pain and mobility Review bloods 3 months for diabetic control

20. BP 148/80mm hg P80 R 16 sats 93% (Nail varnish) Bilateral ankle oedema reduced. Chest – still some crackles present Patient more cheerful GP visits reduced Less interventions by MDT

21. Pre interventionPlanningPost intervention Total visits FebMarchApril GP5 visit 1 telephone 2visits 2 phone 1 PN visit 1 visits 1 telephone DN1 visit0 visits1 visit CM (ACNP)0 visits4 Visits1 visit Total interventions794 Last intervention byACNP on 27/4/12No interventions in May so far!

22. East Sussex Care & Nursing Home Support Service (ESCANS)

23. CQC enforcement action taken in 2012 against the owners of the home to protect residents living at the home CQC - 0/5 standards met at beginning of intervention ESCANS contacted by Adult Social Care (ASC) Safeguarding department – Level 4 SAAR in place. Home suspended by ASC Initial meeting set up with new manager following working day after ASC agreed ESCANS could approach the home

24. Staffing – high turnover/currently recruiting new staff Care planning – generic in nature and not client centred Knowledge base – Limited knowledge of staff around falls and general health awareness RIDDOR reporting – unclear what needs reporting Maintenance checks – To be established Owner support - unknown Management – currently on 3 rd manager in 6 months. Impact on morale and trust for care staff CQC report – impact on staff morale and unknown future of home

25. Provide falls awareness training to the home Complete Environmental review Referred to Dementia In-reach team for support Meeting agreed with Environmental Health to discuss RIDDOR reporting Train staff in mobility aid and wheelchair safety and how to complete regular checks Provide support/advice for onward referrals to community service for residents Case work scenario of 1 resident

26. New staff employed and keen to promote change in culture – evident during training sessions Care plans – rewritten “include detailed information about the needs of people and how they were to be met” CQC July 2012 p11 Knowledge base – “There was evidence that since the September 2011 inspection, staff had undertaken a substantial amount of training. This included challenging behaviour, falls awareness” CQC July 2012 p22

27. CQC visited and now meeting 5/5 standards Safeguarding restrictions lifted by ASC and now open to new admissions Admissions decreased since ESCANS input ESCANS asked to support sister home locally

31. GUIDANCE ON OBTAINING DOCTOR’S ADVICE OUT OF HOURS Is the patient presenting with NEW or WORSENING symptoms? Does their condition require URGENT medical care? There are three possible degrees of urgency as described below. For the best outcome for the patient, and avoid overtreatment by doctors unfamiliar with the patient, which of the three possibilities is most appropriate. Situation One Contact normal hours GP There is a new symptom or worsening of an ongoing problem that could wait for advice from the surgery the next day. If Friday or Saturdays will it wait one or two days. For example: Cough, without fever, shortness of breath, confusion, change in behaviour or appetite Signs of urinary tract infection without fever, severe discomfort, visible blood in urine New onset confusion where there is no change in level of consciousness or onset of difficult behaviours Constipation without significant discomfort or changes in behaviours Skin problem/infection without fever or significant discomfort Fall with no apparent injury Situation Two Contact OOH GP There is a new symptom or worsening of an ongoing problem that warrants urgent assessment by the duty doctor during the period 1830-0800 weekdays or on weekends. For example: Cough with shortness of breath, fever, or significant discomfort Signs/symptoms of UTI with fever, significant change in behaviour Other infection with fever, but patient’s level of consciousness and functional ability not compromised Fall with minor injury or uncertain about degree of urgency Situation Three Dial 999 There is a new symptom or worsening of a ongoing problem that warrants emergency treatment For example: Chest pain: especially if dull, heavy, pressure like Shortness of breath that is severe: patient cannot speak, turning blue, heaving chest Severe abdominal pain: patient restless and distressed Definite stroke: obvious weakness of face/arm/leg, incomprehensible speech Blood loss: heavy blood loss from nose/mouth/vagina/anus Fall where there is severe pain, head injury, loss of consciousness, unable to move or weight-bear Does the patient have a DNACPR or ADRT that precludes hospitalisation or aggressive medical intervention in any circumstances. For situations 2 & 3, complete the Care Home/Nursing Home pro-forma. The assessing doctor, either on the phone, a visit or in A&E, will hopefully have an assessment with information to avoid overtreatment/admission. The goal is to avoid causing unnecessary distress or harm to the patient. Admitting an elderly patient to hospital is often not in their best interests. We hope you will consider the request for doctor’s advice out of hours, carefully.

34. Respiratory conditions Cellulitis UTI/Elimination Falls, soft tissue injuries, fractures Collapse, loss of consciousness Confusion Mobility Nutrition Etc, etc Previously discussed with Kay Muir EOLC Lead: Advance Care Plan, DNACPR POSSIBLE TOPICS FOR STARTERS

37. NEXT STEPS? Where do we go from here? Working group: Care Home representatives + Clinicians + PCT/CCG support + ESCC representation- Quality Review Nurse role?