Title: Healthy ageing in Southwark Care of older people in the community
1Healthy ageing in SouthwarkCare of older people
in the community
- Sam Mayne
- Liz James
- Debbie Sharp
17 September 2007
2The Southwark Vision
- Southwark awarded 1.8m under POPP
- Prevent unnecessary decline in an older person
- Increase the ability of primary and social care
to support older people in crisis - Create time and choices for older people in the
decision making around their long term care
3Outcomes
- Help older people
- have a greater quality of life
- live independently longer
- avoid unnecessary visits to AE and unplanned
admissions to hospital - Avoid premature care home placement
- Focus on active rehabilitation and health
promotion - Embed approach into working practices
4Partnershipagencies involved
- Southwark Health and Social Care
- Southwark Social Services
- Southwark Primary Care Trust
- Guys and St Thomas NHS Foundation Trust
- Kings College NHS Foundation Trust
- South London and Maudsley NHS Foundation Trust
(SLaM) - Southwark Community Care Forum (e.g. Age Concern)
- Care Home providers
5Partnership
- Southwark health and social care has been working
as integrated teams since 2003 - History of close partnership working with acute
and voluntary sectors
6Partnership working
- Multidisciplinary teams are drawn from
7Two POPP workstreams
- 1) Hospital discharge pathway
- Improving the patient journey for those
discharged from hospital - 2) Community pathway redesign
- Proactive multidisciplinary case discussions in
the community to - improve the quality of life for older people
living at home and their - carers by helping them to maintain physical and
mental health, - independence and well-being.
8Hospital discharge pathway
- Improving the patient journey
9Aims
- Reduce long-term placements
- Reduce length of stay and increase early
discharge - Increase numbers at home with complex needs
- Improve choice and decision making for patients
and their families
10How we did it
11How we did it
- Work groups included all key operational staff
from - Acute
- Commissioning
- Voluntary sector
- Social care
- Mental health
- Ensured key staff influenced development of
pathway - involved, engaged and able to deliver change
- Supported by project management capacity
12Early intervention
- Aim to make social work intervention and
assessment at earliest possible point in patient
stay - Additional post attached to Care of Elderly wards
- Do not hold case load
- Main functions
- Build close links to key ward staff
- Ensure one consistent point of contact for
information transference - Link to community resources and key staff
13Savings made
- 300 increase in referrals to Mental Health
Intermediate Care Team - Increase in the percentage of clients referred to
Intermediate Care and discharged home with
supporting services from 5.3 to 11.2 - 1.6 reduction in average length of stay to 11.9
days - Annual savings (2006/07) 511,680
14Evaluation and client information
- Make major improvements to data collection
- Set up service user feedback
- 108 service-users report services are, on
average, good (77 satisfaction rating) - included in the process (73 satisfaction rating)
- treated with dignity and respect (80
satisfaction rating) - find the services are reliable (73 satisfaction
rating)
15Before the further assessment process
16Further assessment process
17Bed based care units
- Offer intermediate care with a widened remit to
include more complex and borderline placement
clients - Domiciliary care teams
- Reconfigured skills mix for more complex patients
at home - Psychology embedded across service to improve
options for management of patients with mental
health needs
18Further assessment process potential savings
19Community
- Link to
- District nurses
- Commissioning colleagues
- Modern Matrons
- Re-admission meetings
- POPP Community Pathway Redesign
- Developing community intermediate care team by
joining hospital discharge and community
multidisciplinary meetings
20Community pathway redesign
- Community multidisciplinary teams (MDTs) for
older people - Maintaining physical and mental health,
independence and well-being
21Workstream aims
- No existing multidisciplinary forum for older
people - gt numbers of older people able to live
independently for as long as possible with a good
quality of life. - Enhance joint working between health, social
care, hospital, voluntary sector etc teams - Link in with existing care at home strategies
(incl. telecare) - Introduce specialist comprehensive geriatric
assessment within a community multidisciplinary
environment - Focus on the high risk/complex patients
(middle/top tiers of the Kaiser pyramid)
22What did we do?
23MDTs Community-based expertise
- Blue italics POPPs funded posts which work
across all MDTs
- Head of Community Services
- District Nurses, team manager Community
Matrons
- Hospital Discharge and urgent care teams
Community MDT
- Voluntary sector co-ordinator
- Social care teams and Manager
- GP Practice staff (e.g. GPs, Elderly Care
Co-ordinators)
24Referral pathways developed
65 yrsgt, living independently at home
Screening tool
10gt hrs of social care support per wk
Health professionals e.g. GPs, nurses, therapists
Social care team
GP
Community Geriatrician
Referral form
Referral form
Social Care Team Manager
Nurse Manager
Agree patients/service users go to next MDT
meeting
25Health screening tool (v3.2)
- New Cognitive decline MMSE lt or equal to 24/30,
normal dementia screen - Falls more than one in past 12 months and not
in falls care pathway. - Incontinence Urinary or Faecal.
- Multiple medications affecting compliance or
other adverse consequence - Complex medical and multidisciplinary needs with
decline. - Care home referral or Increased care package is
being considered. - Hospital readmissions 1 or more in the last
month. - Frequent service utilisation e.g. AE used gt1
per month, SELDOC - Mobility decline (including housebound) in last
6 months with inadequate explanation or
intervention - V3.2 (18 June 2007)
26Benefits of the MDTs for patients and staff
- Fast-tracked, specialist assessment and
rehabilitation (e.g. therapy) - Joint home visits (e.g. Geriatrician and
therapist, Social Worker and Community Matron
etc) - Day hospital review
- Linked into voluntary sector provision
- Proactive, comprehensive review of circumstances
and care packages - Medication use review by PCT Pharmacy team
- Linked into other care pathways (e.g. falls,
assistive technology) - Greater integration in multidisciplinary care
planning - Carer support
- Continuing care assessments (Community
Geriatrician) - Geriatrician liaison, advice and joint home visits
27Case study D
- D is an 87 year old with a 7 hour care package
for personal care. - D has a number of medical conditions which
affects their functioning. Partner was the main
carer but daughter also supported twice a week. - D was presented for community multidisciplinary
case discussion as their partner had recently
died and the daughter was requesting a care home
placement as she was having difficulty coping. - MDT intervention The Community Geriatrician
provided essential clinical information about Ds
conditions and as a result, an urgent OT home
assessment was carried out. - Outcome Ds care package and day centre
attendance was increased, telecare support
provided and voluntary services offered. - D has now been able to return home
28Increasing community expertise
- Community Geriatrician
- Specialist expertise in acute/chronic care of
older people - Clinical leadership/support within the MDT
setting (including pathway planning, operational
guidance etc) - Advisor to health and social care professionals
- Central link to acute care (e.g. records etc)
- Direct link with GPs
- Help train/maintain skills of MDT professionals
- PCT Pharmacists
- Compliance and suitability of medication (as well
as identification of gaps and possible side
effects) - Conduct Medication Use Reviews (MURs) in the home
(x2 pilots)
29- Voluntary sector Co-ordinator (based at Age
Concern) - Ensures link to local networks
- Identifying relevant support
- Fast-tracking referrals
- Promoting voluntary sector provision
- Mental health team
- Raising awareness of managing MH conditions
- Signposting to appropriate services
- Joint assessment
- Developing more effective communication links
30MDT case discussion data
- 123 case discussions (July 06 - March 07)
- Of these
- 119 social care referred (4 by community nurses)
- Majority female 67
- Majority aged between 75-84 41
- Majority White, British 69, Black, Caribbean
11 - Approx 240 referrals expected from April 07-March
08 (approx 5 per meeting) - New health referral will impact on this data
31(No Transcript)
32Savings made to date
- Analysis of acute service usage pre and post MDT
discussion - Sample of people discussed between July-Nov 06
- Outcomes (hospital usage) tracked for 6 month
period after discussion and compared to same
period one year before (controls for seasonal
variance) - 39 reduction in average hospital admissions for
this sample between the two periods - Similar reduction for AE attendances
- Early stages of the evaluation suggest that costs
may outweigh financial savings - BUT Sample reflects very early stages. MDT
developments since Nov 06 may impact on savings.
Evaluation is continuing and will incorporate
post Nov 06 developments
33Ongoing evaluation
- Cost-effectiveness likely to increase due to
- Completion of MDT recruitment
- MDT evaluation processes in place
- Introduction of new health pathway
- Referrals from GPs, Community Matrons etc
screening tool - Impact of development of links between both POPPs
pathways - E.g. Community Geriatrician, HDT involvement
- MDT working potential lt in care packages
34Benefits of community MDT working
Holistic case discussions Supports joint
working, problem-solving and progress-reporting,
ensuring the most appropriate care is in place to
support older people at home
Joint-working increased home visits between
professionals that have never worked together 11
or in teams before
Information sharing helps professionals make a
more informed decision about care planning
Proactive approach The aim is to prevent
crisis situations, e.g. supporting carers more
effectively
Communication Putting a face to a name within a
team, making the relevant links for joined up
working etc
MDT-working in communities Supports existing
integrated working and helps develop more
efficient and streamlined pathways/processes
Skills development - knowledge/understanding of
each others roles is increased etc
35Lessons learned - strategic
- Dedicated resources for change management
- Innovative ways of working management culture
allows for innovation at service level between
health and social care - Early buy-in and involvement of key stakeholders
- Evaluation methodology in place early
36Lessons learned - operational
- Multidisciplinary working
- Within and between teams
- Flexible approach
- Information sharing between different
organisations - Resources
- Early recruitment
- Administrative support
- Inclusion of psychology
37Contacts
- Hospital Discharge
- Sam Mayne, Acting Head of Intermediate Care and
Hospital Discharge - sam.mayne_at_southwark.gov.uk
- Liz James, Project Manager
- liz.james_at_southwark.gov.uk
- Community pathway
- Barbara Hills, Head of Community Services (north)
- barbara.hills_at_southwarkpct.nhs.uk.
- Dr Adenike Dare, Community Geriatrician
- adenike.dare_at_southwarkpct.nhs.uk
- Debbie Sharp, Project Manager
- debbie.sharp_at_southwark.gov.uk