Reshaping Care for Older People “Keeping it real..... a case study” Dundee Partnership Approach

1. Reshaping Care for Older People “Keeping it real..... a case study” Dundee Partnership Approach September 2013

2. Reshaping Care for older people Monday – Podiatrist came for routine visit . Went for my paper, it took the stuffing out of me Tuesday - Not too well today, fell out of bed but did not tell anyone, didn’t use alarm don’t want a fuss. Feel dizzy , not hungry. Told girl from lunch club I am not up for it ,stayed in the house Wednesday – Feeling tired .Meals on wheels came today , didn't fancy them Felt dizzy in kitchen , fell , had to use alarm . Glad to be back in chair .Stayed there all night . That bucket came in handy Thursday – Slept on and off all day in chair. Afraid to move in case I fall again. Friday – Didn’t get up today .Have had nothing to eat since Wednesday or to drink since Thursday morning. Neighbour saw curtains shut , called Daughter who rang GP. GP called , he thinks it’s the tablets so he changed them, took blood and said more tests might be needed .He will phone hospital when back in surgery. Daughter rings GP in the afternoon says Dad is “ off the legs” . GP had already left messages about me with Physiotherapist, District Nurse and for Social work to ask them to call on me. Saturday – Daughter rings Out of Hours at 10o’clock before the District Nurse had even called. “No “ she said “ I can't bring him down I can’t get him out of the chair. “ The OOH GP calls on me. My daughter is very stressed “ it would be better that you go into hospital “she says “so that you can be looked after properly “. I said nothing - best not to. They called an ambulance ,all this fuss. Sunday –In Ninewells it is going like a fair ,even more afraid to move today, what if I fell in here? Can’t hear a word of what they are saying to me so I had better just nod. I think they think I’m daft and I’m not ,I am just done in

3. Reshaping Care with older people January A Nurse came to se me because she said the GP thought I needed a ‘review’ I was asked a lot about myself. I was asked about what I might like to happen to me as I get older We have an ‘Anticipatory Care Plan’ now , I want to stay at home if I can. I was having trouble walking and now I have a stick and an exercise programme to keep me mobile. I have been to classes. I have information on local help and support, my daughter has this too. March Since the assessment I take less tablets. I know which are the important ones because I saw a Consultant with my GP and the Pharmacist from the Practice, they explained it all to me. June When I had a fall ( I was ok) my daughter called the Doctor to tell him. He said he had discussed my case with his team , he would ask the Physiotherapist about me. He called and gave me exercises in the house and a nurse came to check my blood pressure lying and standing and took some bloods. I was told they needed to take an extra pill so I did ,and they checked to see if I was alright. Everyone one of them asked me if I was doing the exercises July When I had another little fall the alarm people told the Physiotherapist and they sent help, I was desperate not to go into the hospital. The person who came did everything for me for a couple of days, helped me with my exercises, took me for a walk, helped me with my pills, made me meals and made me drinks. Then I was ok on my own again. When I was a bit better I went up to the clinic where I saw the Physiotherapist again, the tablets were making me fall – he knew all about that and he said he would speak with the GP team .They organised with the Chemist to alter my pills again. I was asked how I was feeling , I saw that same Consultant in the Clinic. He was pleased with me. November I keep taking the pills they tell me to , I know I have to drink a lot and eat right, I also know if I don’t keep doing my exercises they will all find out….

4. “A Nurse came to see me because she said the GP thought I needed a ‘review’ I was asked a lot about myself....” 95% of people aged ≥ 75 yrs consult their GP at least once every year ,on average they also have 9 contacts through the surgery each year. 1:10 older people ≥ 75 yrs need a home visit ( i.e. can’t get to GP surgery) 1:2 older people ≥ 80 yrs need a home visit – a sharp rise 9/26 Dundee GP Practices working with Medicine for the Elderly Consultants (MfE) on ‘early intervention’ with older people at risk of an unplanned admission 257 older people have been assessed from Sept 2012 to Feb 2013 of these: 181 have required care coordination by the MDT 61 have been referred for MfE assessment in Day Hospital 26 had a carer identified ’ l

5. “ I was asked about what I might like to happen to me as I get older We have an ‘Anticipatory Care Plan’ now” ACPs are part of the new GP Contract and an e-version is due in June 2013 ACPs will be able to be shared electronically by summer 2013 “I want to stay at home if I can.” 2,160 ‘Home Safety Risk Assessments ’ carried out in 1year = 9 per day 900 call -outs per day to Community Care & Response Service ‘community alarm’ = 38 calls per hour =331,191calls per annum 140 hrs per week additional overnight care hours in place in housing with support environments in the city = 7,300 hours per annum 518 hours per week of increased social care hours in response to need Welfare & benefits checks have resulted in £4,507,532 of additional income generated for Dundee citizens in 2011-12

6. “I was having trouble walking and now I have a stick and an exercise programme to keep me mobile. I have been to classes” Joint pathways now enable people to access equipment quickly- this includes equipment needed to support a discharge from hospital 83% of equipment deliveries are carried out within target timescale of 3 days. 2011/12 16,500 items of equipment issued , value £1,038.295 We are about to roll out a validated exercise programme to be delivered in the community to promote bone health and prevent falls “I have information on local help and support, my daughter has this too.” Dial- OP is a new supported telephone and on- line information service for older people, run by older people commenced this year - up to now 28% of calls are about transport & 24% about welfare & benefits Investment in Dundee Carers Centre to deliver additional programmes of support to carers

7. “Since the assessment I take less tablets. I know which are the important ones because I saw a Consultant with my GP and the Pharmacist from the Practice, they explained it all to me.” Locality Pharmacists search for : Older people on ‘high risk’ combinations of drugs as well as those on ‘high numbers’ of drugs A review of medication’ (or polypharmacy ) is part of review of the person as a whole. Locality Pharmacist follow patients up – with ‘face to face’ reviews and they record & monitor change Early data suggests that 25% of people have changes made to their drugs – stopped, started and drug dose adjustments

8. “When I had a fall ( I was ok) my daughter called the Doctor to tell him. He said he had discussed my case with his team , he would ask the Physiotherapist about me. He called and gave me exercises to do in the house and a nurse came to check my blood pressure lying and standing and took some bloods. I was told they needed to take an extra pill so I did ,and they checked to see if I was alright. Every one one of them asked me if I was doing the exercises” Two new ‘locality’ district nurses linked to MfE Consultants and clusters of GPs carry out holistic nursing assessments on behalf of the MDT Locality nurses work differently – seeing people who are not necessarily housebound . Approx 125 assessments undertaken by them in 6 months A new Falls Co-ordinator also links to ‘early intervention’ and to RVH Day Hospital Team

9. Reshaping Care with older people December I didn’t feel well this week I had an awful pain and a cough so we rang the GP and he came out .He said he wasn’t sure what was wrong with me this time and was best I went into hospital for tests they couldn't do at home I saw the Consultant on the ward, the one who knows me and he said I would be home in two days They read my anticipatory care plan they knew I wanted home. They said I had an infection and it would clear with the tablets but I would need extra help for a bit. They said that some of the people who came to see me when I had ‘that turn' earlier in the year would come back for a few days A lady came to see me from the Discharge Team and I was told I could go home tomorrow with something called “ Enablement” to get me going again. “I am not caring what its called I said , just get me home.”

10. A lady came to see me from the Discharge Team and I was told I could go home tomorrow with something called “ Enablement” to get me going again. “I am not caring what its called I said , just get me home.” We have enabled 922 service users in a year providing 86,164 hours of direct care with an average of 35 days per user We need to spread and scale up this work so Medicine for the Elderly Consultants and the wider community team understand their older populations and the older population feel engaged with them.

11. How does this link with our intermediate care bed model in a care home? Step Down Established in 2008, 23 bedded unit within a private care home Now Nurse/AHP led with GP input Dedicated input of care manager from hospital team NHS staffing – Pharmacy and AHP Step Up GP practice are ready to test in intermediate care unit but only with patients from their practice Challenges re cross working with other practices not yet resolved No suitable patients identified – too unwell/diagnosis required requiring acute admission or assessment Challenges Provision for people with advanced dementia - ?? Appropriate Earlier identification of patients in their journey - ?? Home as default Working with an external provider – excellent links with Care Inspectorate

12. Our Approach To Partnership • Relationships • Communication • Clarity of Focus • Momentum in Decisions • Skills of Engagement