Inspiration Day

1. Inspiration Day Thursday 21st March 2019

2. House Keeping • Fire alarm, exits and muster point • Toilets • Phones • Photography • Timings for the day- Workshops • Breaks, lunch and refreshments • Feedback forms • #Best4ESTHER

3. Dr Robert Stewart-Clinical Design Director of the Design & Learning Centre Anna Carlbom-ESTHER Lead- Design & Learning Centre Dr Sarah MacDermott-Clinical Chair of DGS CCG

4. ESTHER Philosophy in Theory “What matters to you?” ESTHER Inspiration Day 21 March 2019 Dr Robert Stewart Clinical Design Director Design and Learning Centre for Clinical and Social Innovation Anna Carlbom ESTHER Lead Design and Learning Centre for Clinical and Social Innovation

5. Design & Learning Centre for Clinical & Social Innovation Co-Designing Better, Safer, Cheaper and Different Care An Innovation Space for Professionals, Citizens, businesses & academics Finding the right solutions to make a real difference Removing organisational & professional barriers

6. ESTHER Philosophy of Care culture strategy services

7. 5 Levels of Continuous Quality Improvement Changing culture and strategy for better outcomes Bringing together culture and strategy with better outcomes M

8. International philosophy co-implemented across Kent and Medway Co-implemented in Thanet CCG Concept from Sweden Singapore collaboration Planned in DGS and Swale CCGs

9. International philosophy co-implemented across Kent and Medway Concept from Sweden

10. Concept from Sweden 1 2 3 Why did Sweden develop the ESTHER Philosophy? What outcomes did the ESTHER Philosophy achieve? How did Sweden implement the ESTHER Philosophy?

13. https://vimeo.com/318398646/5f0b6caf9d

14. Co-implemented in Thanet CCG Co-implemented in Thanet CCG

15. Co-implemented in Thanet 1 2 3 Why Thanet? What has Thanet achieved? ART successful Local perspective How did Thanet co-implement?

16. Planned in DGS and Swale CCGs Planned in DGS and Swale CCGs

17. Planned in DGS and Swale CCG 1 2 3 Why DGS? Using ESTHER as the OD tool for MDTs What timescales? Has started with Ambassadors, Coaches,Trainers and Cafes Planned implementation DLC developing local capability

18. Implementation in DGS (Dartford Gravesham and Swanley) Governance – Local Care Implementation Committee Stakeholder organisations to nominate an ESTHER trainer MDT Co-ordinators job specification includes: ESTHER positive ESTHER Ambassadors ESTHER Café organisation in each MDT quarterly Design and Learning Centre co-locating ESTHER resources Aim - 10 local trainers DGS and Swale by July 2019 Aim – Reach 1500 health and care professionals by 2020 Core to the organisations providing health and social care including core induction initially Virgin and KCC

19. Singapore collaboration Singapore collaboration

20. Singapore collaboration 1 2 3 Implementing together with Sweden as three sites learning and supoorting Developing joint ideas in evaluation and clinical co-operation Hosted visits Regular international webinars

21. ESTHER Philosophy of Care “What matters to YOU?” Local clinical leader’s perspective Dr Sarah MacDermott Clinical Chair and local GP, DGS CCG Dartford Gravesham and Swanley Clinical Commissioning Group

22. ESTHER Philosophy of Care “What matters to YOU?” • Developments • e-learning • Carers app • External connections in UK and internationally • Any reflections, inspirations and questions from you?

23. What difference has ESTHER already made?

24. System learning - Informed East Kent • Frailty Strategy • Raised priority of person-centred care • Many small improvements – • Little things matter! • Improved ESTHER & care professional individual experiences • Empowering self-care Transforming MDTs, Primary Care Networks and Communities

25. Anna Wilson-Local Care Commissioning Programme Manager DGS

26. MDTs in DGS – the patient centred approach

27. MDT localities 6 localities across Dartford, Gravesham & Swanley (30-50k patients each) Staff aligned to localities from multiple health & social care providers 3 MDTs are ‘live’. Remaining 3 planned to go-live throughout April Weekly MDT meetings with GPs managed by MDT Co-ordinators (currently CCG staff) Patient nominations welcome – actively working through GP frailty lists and focussing on elderly, frequent attenders at A&E

28. Patient example - MD • 71 year old female • FRAILTY SCORE of 33, which equates to ‘MODERATE FRAILTY’ • Multiple LTCs: • COPD • TYPE 2 DIABETES • CHRONIC KIDNEY DISEASE • CHRONIC LOWER EXTREMITY OEDEMA • NEW ONSET RECURRENT FALLS • NEW ONSET COGNITIVE DECLINE

29. MD’s social history • SOCIAL HISTORY: • Widowed • Lived alone in 2 storey house with upstairs bedroom • Help from Neighbour who was assisting with finances, home modifications and direct patient care • There were some safeguarding concerns around her care

30. MD in crisis • MD had an emergency admission to Hospital in October 2018 (as MDTs were launched) – this was for a lower respiratory tract infection and dehydration. Home therapy previously in place had failed and social vulnerability had been identified by the GP • MD was discharged to an intermediate care unit after 24 hours in Hospital and she stayed in intermediate care for 20 days to rehabilitate • MD was placed on the community nursing caseload when she returned home as she was a housebound patient

31. So what did the MDT do? • We discussed MD after the GP nominated her. We agreed, as a team, the GP would contact the patient and discuss/initiate care while MD was still in the intermediate care setting – discharge date was agreed with staff and MD • A medication review was undertaken by the GP upon discharge – medications optimised for lower extremity oedema • A home visit was undertaken by the community matron to review MD’s LTC management. COPD therapy was optimised, a Diabetes review was undertaken and this is now well controlled. GP was notified of incontinence and a prompt referral and assessment was initiated • MD was reviewed by a community navigator and social services – an assessment of vulnerability/safeguarding was undertaken in the patients home. MDs care needs were assessed and the patient wished to be supported individually in her own home

32. How has this helped MD? • LTCs now well controlled – MD has been discharged from the community matron caseload • MD continues with housebound care via a number of services • A recent emergency admission for Anemia due to GI bleed resulted in a six day stay for investigation and treatment. MD was then discharged home successfully to continue with her current care plan

33. How has this helped the MDT? • Everyone in the same room, at the same time, discussing the same patient - effective communication & very patient focussed • Immediate updates from a number of different providers • Urgent actions taken away by staff and followed up as required • MDT coordinator able to keep track of the patients journey and relevant actions for the group etc

34. ESTHER café’s • We are working with our ESTHER colleagues to arrange ESTHER cafes in DGS throughout April/May • A small selection of practices have been chosen to provide case studies for us to focus on – patient consent will be gained • Plan is to hold at least one ESTHER café, once every quarter, in each of the 6 DGS localities

35. Local Care Commissioning Programme Manager - Anna Willson Anna.Willson@nhs.net 03000 424912

36. Ann Taylor-Chief Executive- Hilton Nursing Partners

37. Home To DecideEsther Philosophy in Practice Ann Taylor CEO Hilton Nursing Partners anntaylor@hiltonnursingpartners.org.uk 07715 014086

38. How I Met Doris

39. Can I Come Home?

40. Out of that hospital gown

41. Home for Manicure & Wine

42. But Doris didn’t have family: • Lived alone • Assessed for Nursing Home Placement in Hospital • Frail, elderly and worried Her concerns: • Did I shut the front door? • What about telling my friends and neighbours • Where is my handbag? • Is this how it all ends??????

43. Benefits of Esther: • To support people who believe they are capable of returning home. • To allow people and their families time and space to make informed decisions about future care. • To provide one high quality, person centred trusted assessment in the right place - HOME. • To provide support, advice and advocacy to people and their families regarding ongoing options available. • To reduce unnecessary residential care admissions.

44. Esther’s Journey: • Esther is likely to remain living independently at home for longer. • Esther and family are given time and space to fully consider all options. • Esther receives a more appropriate assessment at home. • Esther is no longer a DTOC or ‘stranded’ patient. • Esther is in control and has choice. • Esther has been given her life back!

45. Case Study: Admitted to hospital with a fracture that could not be surgically repaired. Main carer was his daughter who was living with her own disabilities. Heading for residential care – as would be bedbound and deemed as unsuitable to return home, due to other complex health conditions. Eager to return to his daughter – a co-dependant relationship. Was referred to Home to Decide. After his Hilton journey, this man was able to remain at home with his daughter – his only wish. A package of care was implemented alongside Carer Support and Telecare assistive technology.

46. Feedback I wanted to thank you for recently looking after my Dad, who was admitted to hospital in February, following a fall and with a chest infection. I did not know your service existed, but with the 3 days, 24hr support, followed by regular calls supplied by you, this allowed us to set him up at home, where he now continues with private care. Excellent service from a great team. Having this service allowed me the time to make the best decision with Dad.

47. Feedback All of your nurses/carers looking after my mother at her home were excellent in every respect. They were all thoughtful, kind, patient and professional under Claire’s guidance. Also, a special thank you to Claire, for giving me much needed emotional support. The girls deserve a thank you for their positive contribution to the company. Well done.

48. Cathy Bellman-Kent and Medway STP Local Care Lead

49. Esther Inspiration DayLocal Care - ESTHER Philosophy in Practice 21 March 2019

50. Local care: • The Kent and Medway Sustainability and Transformation Plan outlines the intention of the Kent and Medway health and care system to deliver an integrated health and social care model that focuses on delivering high quality, outcome focused, person centred, coordinated care that is easy to access and enables people to stay well and live independently and for as long as possible in their home setting. • Additionally, the Kent and Medway Case for Change states that the first priority is to develop more and better Local Care services; • Local care being the delivery of integrated health and care services close to where people live, with • A collective commitment of the health and care system in Kent and Medway to fundamentally transform how and where we will support people to keep well and live well.