Care Home Improvement vanguard Anna Makepeace Project Manager By 2030 the number of older people with care needs is predicted to rise by 61 5 of all emergency hospital admissions in Hertfordshire involve patients resident in care homes ID: 586464
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East and North Hertfordshire:Care Home Improvement vanguard
Anna Makepeace, Project ManagerSlide2
“By 2030 the number of older people with care needs is predicted to rise by
61%”
“
5% of all emergency hospital admissions in Hertfordshire involve patients resident in care homes
”
Rising pressure on care homes:
Unplanned use of health services (e.g. GP, 999)
Delayed Transfers of Care
Staff pressuresPoorer resident outcomes
Hertfordshire BackgroundSlide3
East North Herts Demographic background Slide4
Our Vision
To deliver an enhanced model of health and social care to support frail elderly patients, and those with multiple complex long term conditions in the community in a
planned, proactive and preventative
way
“
”Slide5
Confident staff
in Care Homes
Multi-disciplinary
Team
Rapid
Response
Effective
Technology
Complex Care Framework
End of Life ABC training
Workforce
Rapid Response
Early Intervention vehicle
Red Bag
Trusted Assessor
Integrated data and analysis using MedeAnalytics
Technology in Care Homes
Targeted support for care homes
Medicines Optimisation
Aligned GPs
Frailty service
HomeFirst
Programme OverviewSlide6
Independent assessor to facilitate discharges from Lister hospital to residential and nursing homes 6 days a week
We want to:
Facilitate
the discharge of patients into a care homes to avoid unnecessary delays
Increase the bed flow and statusReduce mis
-communication between the hospital and Care HomeReduce the need for Practitioners needing to come into the hospital to assess, freeing up time and resources
Trusted AssessorSlide7
Key partnersSlide8
Patient medically fit for discharge
Care Home receives assessment, agrees it
Trusted Assessor
completes assessment
Patient transferred back into the Care Home
Discharge processSlide9
Work within the
hospital discharge team and social services
based at Lister Hospital to act on behalf of social care providers to support and facilitate timely and safe discharges from hospital to care settings
Work with agreed assessment formats (standardised across county). Undertake
assessments and re-assessments on behalf of care providers in HertfordshireWork in partnership with care settings and the hospital to find solutions to issues arise that delay dischargeWork with relevant ICT systems, including social care and NHS.
Provide full evaluation for reporting purposes on assessments, information dissemination, discharges, bed days saved and write monitoring reports as required.
Roles and ResponsibilitiesSlide10
“Trust with the care homes is key to the project”
The A
ssessors
are employed by the Care Association (HCPA) and works on behalf of the homes
It is important that care homes can truly trust the assessor and see her as independent. This is the message we give to the homesThe
Assessor has experience of working in the health and social care sector as well as working within the hospitalThe assessor will act to champion homes and highlight needs/challenges which may not have been picked up in the
past and acts in the homes best interest
Working with the Care HomesSlide11
Ongoing
Recruitment to second post. Service become 6 days service
November
3 month evaluation
Feb
6 month evaluation
Roadmap
On track
Progress
2nd August
Trusted Assessor Go LiveSlide12
Challenges
How are we tackling
this?
Access
to ICT systems, informationNHS honorary contract. Working closely to partners to understand the different systems.
Recruitment to post (not on NHS terms and conditons)Shared on partner job sites.
Care Home buy inHCPA employ individual = ‘independent’Engagement with care homesContinuous learning and best practice
Information GovernanceNHS honorary contract. Signed up to organisation’s policies. Lots
of different ways for referral pointsWorking closely with discharge team & social services to map them. Based in both offices to help reduce gap. ChallengesSlide13
Evaluation
Proposed metrics are as follows:
% of days saved as result of the Trusted Assessor
% of discharges using the Trusted Assessor
% of re-admittances to hospital% of homes using process
Location of referralsNumber of assessments completed Time from referral/ assessment to actual dischargeAverage time to complete each assessment
Compliments/ Complaints