Shifting the Balance of Care Models, Pathways and People stories

1. Shifting the Balance of Care Models, Pathways and People stories Stuart Cumming Bette Locke Kathy O’Neil January 2014

3. The Kerr Report -2005

4. 2014 - How far have we shifted? 2020 Vision “Everyone is able to live longer and healthier lives at home or homely setting” (SGHD) NHS Forth Valley Integrated Healthcare Strategy “Our focus now is to fully embed the new and integrated models of care across the range of care settings from acute through to primary and community care facilities.” Primary Care Development Plan “Shifting the balance of care away from reactive episodic care in an acute setting to team based anticipatory care closer to people’s homes is a vital part of implementing our strategy”

5. Getting the Balance Right – Embedding Care in Communities HAI HEAT RTT Lifestyle • TTG LTCs Front Door ACPs SBC Acute Focus Admission avoidance Primary Care Focus

6. The demographic challengePopulation Trends Forth Valley 2013 - 33 Overall increase 10% +33.6% +73.7%

7. NHS Scotland - Whole system working -Secondary Care Impact

8. Kerr Theme Continuous, integrated and preventative care

9. Anticipatory Care “Doing the right thing for the right person at the right time with the right outcome – every time” Anticipatory rather than reactive approach Co-ordinated and planned care Improve communication and 24/7 partnership working with patient and family as partners in care Workforce – education, training, communication, capacity, planning Share information appropriately (KIS) 6258 in Forth Valley ACPTriggers Situation Long term housebound Complex care package or in receipt of respite care Entry to care home* or community hospital After discharge from unplanned admission Frequent OOH contacts Carer stress Condition Deteriorating long term condition Requiring specialist nurse Placed on palliative care *, dementia, learning disability or mental health register Clinical Assessment SPARRA(?>40) Polypharmacy Falls assessment Recognised as vulnerable

10. Anticipatory Care - Avoiding unnecessary hospital admissionMargaret’s story Margaret age 84, lives alone, diabetic, CHD and has been admitted twice in 12 months confused ?CVA. Diagnosis UTI /low sodium Discussion with Margaret and her daughter ACP developed Key Information Summary (KIS) highlighting Margaret is prone to UTIs cause delirium. KIS accessible to PHCT/OOH/NHS 24/SAS Polypharmacy review PHCT meeting to raise awareness of management of delirium Power of attorney in place MECS Emergency antibiotics in house Daughter’s contact details available

11. Change Fund Reshaping Care for Older People Irene Warnock Anticipatory Care Planning Assessment

12. What is Anticipatory Care Planning? Many interpretations. Anticipatory Care Planning- allows people to think about their future care needs at the same time allowing difficult conversations to be addressed if desired. Person centred goals are set and signposting to available identified needs. For us as a team we are looking at how an anticipatory assessment influences outcomes and how this process can be mainstreamed in future..

13. Achieving their “Good Life”. The Vision of Anticipatory Care Planning Team is to: Ensure the people of Stirling and Clackmannanshire lead as healthy a life as possible in a homely place of their choice within a culture of person centred, safe and effective care. Enabling them to plan for future care and ensuring they achieve their “Good Life”.

14. The interview is a conversation, not a tick box exercise The team are trained to manage difficult conversations and have a wide knowledge of local services The interview is a conversation to allow flow from the patient. Exchange Conversation where all partners are equal. If a follow-up meeting is required this can be arranged, or a phone call. If any tests eg blood, MSU or repeat B/P are required these are included in the visit. If an ongoing need requires to be met then these patients will be referred to the appropriate person.

15. “What makes your life good?” “What makes your life good?” The answer given sets the tone of the conversation and is reflected upon at the end of the assessment. This acts as an outcome measure to suit the patients needs. Goals that people aim for have been mostly easily met and ensures we are performing a person centred assessment with a positive outcome at each visit. Sams Story

16. Kerr Theme Care geared towards managing long term conditions

17. Managing Long Term Conditions and Complex Care Condition Management Complex Care and Co-morbidities Self Management Education and Training Multidisciplinary work and communication Effective use of technology (communication and care) Links with WSW, ACP and preventative approach

18. Supporting long term condition managementand Shifting workload out across the interface Increased range of community services Near Patient Testing Anticoagulant monitoring Direct access to diagnostics Pre-clinic, pre-diagnostic, pre- chemo tests Improving access and care Admission alternatives/ Early discharge Primary Care LTC clinics and management plans Physical Health checks for long term complex mental health needs Minor Surgery, Joint Injections Agreed processes Shifts need to be communicated, planned and agreed (e.g. prostate cancer) Clear Guidelines- outline roles and responsibilities Ensure safety and quality- infrastructure, capability and capacity Support professional development

19. Laura age 41 Rapidly progressive MS Communication, airway, mobility, care and nutritional issues Medication management and symptom control Childcare Carer Support “I want to spend more quality time at home with family and friends” Laura 2006 • Home adaptations • Telehealth • 24/7 care package • PEG feeding • Respite care • Collaborative Work with Primary Care, REACH, Complex Care and Local Authority Laura is still cared for 24/7 at home in 2014. She has had no unscheduled hospital stays in 7 years

28. Learning….? Need for consistency of service delivery and collaboration Increased awareness of anticipatory care Need to recognise the capability of community services Individuals and primary care manage risk in community at all times

29. Shifting the management of long term conditionsDiabetic care In 1995 all diabetics attended hospital based diabetic clinics Now all Type 2 diabetics primarily managed in the community Community workforce (GPs, PNs, DNs) upskilling and training Supported by GMS contract (2004) and LTCC (2006) Medication co-ordinated and complications managed by PHCTs Focus on prevention and lifestyle interventions and self management enabled Improved interface links with specialist nursing Only most complex seen by diabetologist NB. Workforce capacity Prevalence of diabetes in 2000 2.8% population, 2013 4.4% population

30. Kerr Theme Care embedded and accessed in communities

31. RESHAPING CARE FOR OLDER PEOPLE IN Forth Valley THE RIGHT SERVICE - IN THE RIGHT PLACE - AT THE RIGHT TIME

32. Our Mission… “to enable older people in Forth Valley to live full and positive lives in their own homes or when this is not possible within homely settings within supportive communities.”

33. Partnership Approach Reshaping Care for Older People is being delivered through a partnership approach between Local Authority, NHS, Third and Independent Sectors in Forth Valley. Joint Strategic Comissioning Plans were developed and consulted upon early 2013 People said….

34. More joined up services, not just joined up structures • Improved ability to co-ordinate care and support around individual needs • Shared roles and responsibilities • All services working to common outcomes • Streamlined systems and Shared information • Less duplication, less hurdles to jump between agencies • Better care for individuals, particularly those with complex needs.

35. People don’t want health care or social care, they just want the best care. • Less complexity • Easier points of access • Easier to navigate • Co-ordinated care from • joined up services • Services “planned • around me” and • working to common • outcomes • integrated services which do feel truly seamless

36. Impact on Services

37. Priority Areas for Change Preventative and Proactive Care in the Community and Support at Home Anticipating and Preventing Unnecessary Hospital Admission Effective Care at Times of Transition (including effective flow through hospital) Reshaping Hospital and Care Homes

38. Preventative and Proactive Care in the Community and Support at Home • Keeping Well • Early Preventative approaches • Early Intervention • Choice & Control (including SDS) • Community Based Supports • Development of Third and Independent Sector Capacity &Co-Production approaches to community support services • Increased Community Capacity and Increased Co production Also includes. • Significant Growth in Telehealthcare • Responsive Adaptations and Equipment Services • Support for Carers • Proactive and responsive support for carers • Effective Respite and support models in place

39. PARTNERSHIP INNOVATION FUND: Reshaping Care for Older People Royal Voluntary Services Community Transport and Good Neighbours service aims to reduce social isolation in people of 65yrs+ by helping them to stay independent at home. They provide a volunteer based transport service to those unable to access public transport. Volunteer drivers are available daytime, evenings and at weekends. Good neighbour support can include grocery shopping, going for a walk, completing forms, small household tasks or just sitting with a cuppa for a chat.

40. Supporting Carers

41. Anticipating and Preventing Unnecessary Hospital Admission Personal Planning with individuals who have significant health and care needs. Remodel pathway of acute care for frailer older people Clear pathways and interventions for individuals who Fall or are at risk of falling Rural models of care and support will be extended Support for Carers- Effective Respite and support models in place. Third and Independent Sector Capacity & Co-Production approaches will be developed to support anticipatory models.

42. Supporting Acute Flow – Allied Health Professions (AHP) 7 Day Model of Working

43. Developing Enabling Services Delivery of an INTEGRATED Intermediate Care service, with single access points for assessment and review including the following: • A responsive 7 day model • An effective Intermediate Care Bed Model • Reshaped Home care with Re-ablement Pathway as the norm for individual identified with new or increasing “needs” • Reshaped internal Day Care services • Reshaped Dementia Pathway which facilitates early diagnosis, post diagnostic support and personal planning. • Moving away from statutory provision to that of alternative supports through community, third and independent sector supports.

44. Re-design of Homecare Services

45. Reshaping Hospital and Care Homes Models of care which use hospital and care home resources most effectively • Embedded Intermediate Care Bed Model • Remodel Community Hospital Beds • Ultimate integration between health and social care models • Business Case for Stirling Care village • Reduced average length of stay long term care • Reduce rate of care home place per head of population. • Reduced Acute Hospital Bed Days >75yrs • Alternatives to admission including Hospital @ Home

46. Supporting Care HomesPreventing Admission

47. Supporting People to Remain at Home Mrs B was admitted for a short stay assessment placement following a fall while on holiday. She was in severe pain upon admission, requiring high levels of pain medication and with subsequently, severely limited mobility. She required the support of stand-aid equipment to rise and the support of 2 staff for all transfers. Mrs B’s main outcome was to improve her independence to allow her to go home with minimal supports. She met this outcome, returning home, walking with the assistance of a walking stick, with the support of Reablement services. She was visited 3 months following her period of rehabilitation, and was found to have returned to activities such as going to the shops and to local groups in her town. She had accepted a small package of support from a framework provider to assist her with her personal care each day, but was otherwise largely independent.

48. Pause for thought.. • Supporting People at Home • Intermediate Care Services….. • Next slide Stirling Care Village

49. A Care Village in Stirling A Health & Social Care Partnership Venture

50. Stirling Care Village Scope 116 bed integrated care hub, 5 GP Practices, Urgent Care, GP OOH, Diagnostic X Ray & U/S, Ambulance Station, FV College partnership. Out with Project Scope Housing Retained Stirling Community Hospital