New Care Models and the Care Home Vanguard Programme

1. New Care Models and theCare Home VanguardProgramme Lesley Bainbridge November 2016

2. Vanguard = New Care Models5 Year Forward View [NHSE 2014] Challenges, plans, the future Tax funded, free, evolving Not easy, but achievable

3. Gaps Health and wellbeing Care and quality Funding and efficiency Prevention and self care Care divisions Demand, efficiency and transparency

4. Vanguard Models Primary and acute care systems [PACS] Multispecialty community provider [MCP] Enhanced care in care homes [EHCH] Acute care collaborations [ACC]

5. Vanguard Models PACS new approaches to urgent and emergency care improving coordination reducing A&E pressure 2. MCP specialist care out of hospitals into community EHCH joined up health care services 4. ACC integrated systems joining primary, secondary, community and mental health

6. Our Approach Work Streams: Commissioning, Contract, Payment Involvement, Engagement, Communication Evaluation, Monitoring Outcomes Workforce Pathway of Care

7. Pathway of Care [PoC] Enhanced Primary Care TECS Dementia Nutrition and Hydration Responsive Care End of Life Medicines Management

8. What is a PoCcer? Safety Quality Experience Workers and Deliverers of Metrics

9. The Model Each home has a link practice Each practice has a lead GP Nursing homes have an older person’s nurse specialist Weekly ward round Virtual ward round

10. Enhanced Primary Care Literature review: case management works, not about numbers but complexity, has to be equity within teams and equity across the spectrum of need Nurse A [210] and Nurse B [78]: nurse A twice as likely to attend A&E, 36% more likely to be admitted to hospital, more likely to be discussed at virtual ward

11. TECS Diagnostics: NEWS Normal Ageing: can have severe infection in the absence of typical signs and symptoms Virtual Ward: old age psychiatrist, community geriatricians, nurse specialists, GPs and others Software solution to access records, make referrals and capture activity

12. Dementia Diagnosis bespoke pathway Culture and care delivery dementia is considered normal, not an exceptional state for care home residents Transition of care enhancing and streamlining the admission process moving in to permanent care

13. Nutrition & Hydration Dedicated dietetic team Theory to support UTI point of care testing Normal Ageing: alterations in barriers- skin, lungs, GI tract, permit invasion, loss of capacity of immune cells, decreased antibody responses to vaccines, disease burden, communal living, devices

14. End of Life Care Delivery aligned MacMillan nurses with each home Data baseline of preferred place Primary Care audit of practice of palliative care meetings and upkeep of register

15. Responsive Care Hospital alternatives intermediate care Audits: Eastwood x2, hospital discharge support, winter beds, assessment beds, DToC, frailty census lack of MH IC IV administration at home: x2 new pathways

16. Medicines Management Pathway care home focus, waste Practice access, administration Communication electronic, reviews

17. Metrics: Task and Finish Groups

18. Successes to date Challenges to date Stabilisation of A&E activity Lowest NEL admissions for UTI since 14/15 Reduction in ONS supplements Reduction in antipsychotic prescribing costs OP attendances Deaths in hospital

19. Meet the PoCcers 9 organisations, 8 disciplines

20. System Transformation PlanSTP Dr Dan Cowie

21. * Ref: JSNA(s), CCG Outcomes, PH Outcomes

22. “A place-based system ensuring that Northumberland, Tyne and Wear and North Durham is the best place for health and social care” Collaboration/ NCM STP Transformation Areas STP Delivery Areas Cross cutting themes LHEs Closing the financial gap 1 Learning Disability services – TLP (Adults and Children) Northumberland and North Tyneside NSECH Size of residual financial challenge by 2021 PACS / ACO £641m Financial challenge Cancer Alliance and Strategic Delivery 4 GHFT and NUTH collaboration Newcastle Gateshead 2 EHCH and MCP/PACS Mental Health 5YFV (Adults and Children) Summary Solutions South Tyneside, Sunderland and North Durham STFT and CHSFT partnership UHND 3 Women (LMS and Better Births and Children’s (0-19 years) MCP

25. System Transformation Plan and New Care Models Dan Cowie Lesley Bainbridge

26. STP: out of hospital NCM: mcp, pacs General Practice Forward View at scale and with resilience Community services & social care Intermediate care Hospital interface Voluntary &third sector Person & community resilience

27. Care + Wellbeing Model Individual + Community Resource + Resilience building Closer-to-home, needs-based, responsive and proactive care Construct GP registered lists + 30,000-50,000 cohorts Care + Wellbeing Partnerships NTW-ND Collaborative Out Of Hospital Model Collaborative Care Care navigation/links Multiple LTCs Frailty Care Homes Telecare Recovery @ home Rehabilitation Recuperation Re-ablement – Bed + non-bed Equipment Specialist Support LTCs @ home Therapy + Nursing specialist care End of Life Dementia Mental Health Transitional care – discharge to assess Health Social MDTs GPs Health Social MDTs GPs SPOA / 111 Continuity ofCare Care + Support planning – LTCs Telehealth Home-based domiciliary care Prevention – 1st + 2nd Health Social MDTs GPs Intermediate Response Pharmacy Hospital Interface Rapid Response Bed and Non-bed IC nursing + therapy Rapid Domiciliary Services Crisis Response Mental Health Health Social MDTs GPs Community Clinics/Hubs/ Diagnostics Urgent Care Ambulatory out-reach pathways Rapid Access In-reach clinics WIC / A&E Same Day Care 24/7 day urgent care Illness/aliments Self-care Third/ Voluntary/non-statutory Housing Schools Jobs/ Leisure Probation Prevention + Wellbeing Early Years + 2nd life-style prevention Networks community Empowering People + Communities 6 principles + Community Approaches + Asset Building Self Families Integrated commissioning New Payments New Contracts System Leadership System Governance Outcomes Estates, Transport, Equipment Collaborative culture IM + T Workforce

28. Case Study: Newcastle Gateshead CLINICAL The redesign of the care pathway focuses on 7 key areas: • RESPONSIVE CARE: • rapid response intermediate care nursing and therapy, • expansion of community intravenous medication administration • ENHANCED PRIMARY CARE: • case management for all those living with frailty, • practice aligned multidisciplinary teams, • access to specialists via virtual ward approach • MEDICINES MANAGEMENT APPROACH: • pharmacists as core members of general practice and care home teams • EoL drug supply service • Flu vaccination programme • Improve discharge pathways • END OF LIFE: • using prognostic indicators to recognise palliative and end of life, • best practice guidelines for practice palliative care meetings, • alignment of MacMillan nurses to care homes as well as GP practices • TECHNOLOGY: • improved data sharing including bespoke transfer of care standards for care home residents, • enhanced care delivery through telehealth apps HYDRATION AND NUTRITION CARE: introduction of technology and facilitation of work based learning through bespoke dietetic support team • DEMENTIA: • bespoke pathway for dementia diagnosis, • crisis response to challenging behaviour, • improving health and wellbeing through meaningful activities INTEGRATED PROVISION & COMMISSION PATIENT EXPERIENCE person-centred WORKFORCE SAFETY/ QUALITY • ENGAGEMENT: • Development of a Participation and Engagement Programme (incl. self care management) • ‘I’ statements, feedback from patients and carers • UP-SKILLING: • Competency framework: covering 3 levels (general, specialist and advance practitioner) to understand potential skill gaps • Cultural change to implement new ways of working • Provider Alliance Network (PAN) to enhance collaboration • Integrated commissioning: development of a co-commissioned platform for all care home, intermediate and reablement service • EVALUATION: • Revision of Standard Operation Procedures (SOP) and clinical protocols • Learning fast: analysis metrics and outcomes of the programme

29. Frailty : LTC FrailtySyndromes Identifying Recording + eFI Frailty Fit Mild Severe Moderate LTCs Single Multiple Assessment of Needs (in practice) Comprehensive Geriatric Assessment (in community) LTC Care link workers healthy living passport Year of Care multi-morbidity clinics care planning Community MDT emergency health care plans palliative & of life care