1. PRIMARY CARE CONTRACT NURSING & RESIDENTIAL CARE HOMES Right place, Right time, by the Right person Shivaun Aveston, Transformation Lead

2. NHS OUTCOMES FRAMEWORK ‘ Right place, Right time, Right person’ Domain 1Preventing people from dying prematurely √ Domain 2 Enhancing quality of life for people with long- term conditions √ Domain 3 Helping people to recover from episodes of ill- health or following injury √ Domain 4 Ensuring people have a positive experience of care √ Domain 5Treating and caring for people in safe environment and protecting them from avoidable harm √

3. The CCGs 5 year Clinical Strategy & Joint Health & Wellbeing Board To improve care for frail elderly individuals To allow patients to die with dignity and compassion and in their place of choosing Older people in Suffolk have a good quality of life.

4. Investigation into provision of GP services to care homes has shown that most care homes allow residents to choose a GP. This can result in different GP’s visiting a single care home to see different patients This is an inefficient use of GP time and resources, but can also cause problems with communications as nursing homes have to deal simultaneously with several different systems for visits Chronic disease management and prescription requests many homes would prefer their residents to be registered with just one GP surgery and have a weekly ‘clinic’ to deal with minor problems and chronic illness. RCGP Report Preparing for the Future (2012) states:

5. HEADLINE COSTS 2011/2012 Emergency Admissions 6m A&E 2m Ambulance Call outs 2m Care homes represent 25% Ambulance call outs 25% of falls originate from Care homes

6. TOP 10 REASONS FOR ADMISSION TO HOSPITAL Hip Fractures UTI’s Pneumonia Disorientation Femur Fractures Heart failure Respiratory infection Falls Cerebral infarction Senility

7. KEY ISSUES FOR CARE HOMES High level of different GP’s Key time for admission are within OOH Time waiting for clinical support Advance Care plans overridden Untrained staff Staff competencies Lack of specialist provision – Physio,OT

8. THE STORY SO FAR Small Pilot in East Suffolk – 36 Care Homes Nurse practitioner/GP/Nurse offering additional support Inequalities in the provision of care across the patch CCG want to spread good care and equity to this marginalised group and provide a better patient experience for them OUTCOMES Improved clinical care Reduced admissions to hospital Reduced call outs to OOH Reduced ambulance call outs

9. KEY COMPONENTS OF THE CONTRACT October – March initially 29 practices aligned to Care homes Weekly ward rounds- proactive management Protocol Screening- Dementia & Falls Care Planning, Advance Care Planning (Yellow Folders) Medication Review Follow up after admission/OOH Multi- Disciplinary approach Support Care homes through training

10. NOT IN SCOPE EMI Units Sheltered Housing Private Retirement Schemes Learning Disability

11. IMPACT EVALUATION Questionnaire- Pre & Post Activity Report (GP’s) Clinical Audit Care Homes Dashboard

12. CONTACT DETAILS Shivaun Aveston Transformation Lead, Redesign Team Rushbrook House Ipswich shivaun.aveston@ipswichandeastsuffolkccg.nhs.uk 01473 770131 Mobile: 07944212642