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Healthy ageing in Southwark Care of older people in the community

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Barbara Hills, Head of Community Services (north) barbara.hills_at_southwarkpct.nhs.uk. Dr Adenike Dare, Community Geriatrician. adenike.dare_at_southwarkpct.nhs.uk ... – PowerPoint PPT presentation

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Title: Healthy ageing in Southwark Care of older people in the community


1
Healthy ageing in SouthwarkCare of older people
in the community
  • Sam Mayne
  • Liz James
  • Debbie Sharp

17 September 2007
2
The 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

3
Outcomes
  • 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

4
Partnershipagencies 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

5
Partnership
  • Southwark health and social care has been working
    as integrated teams since 2003
  • History of close partnership working with acute
    and voluntary sectors

6
Partnership working
  • Multidisciplinary teams are drawn from

7
Two 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.

8
Hospital discharge pathway
  • Improving the patient journey

9
Aims
  • 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

10
How we did it
11
How 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

12
Early 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

13
Savings 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

14
Evaluation 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)

15
Before the further assessment process
16
Further assessment process
17
Bed 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

18
Further assessment process potential savings
19
Community
  • 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

20
Community pathway redesign
  • Community multidisciplinary teams (MDTs) for
    older people
  • Maintaining physical and mental health,
    independence and well-being

21
Workstream 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)

22
What did we do?
23
MDTs Community-based expertise
  • Blue italics POPPs funded posts which work
    across all MDTs
  • Head of Community Services
  • Community Geriatrician
  • District Nurses, team manager Community
    Matrons
  • Hospital Discharge and urgent care teams

Community MDT
  • Voluntary sector co-ordinator
  • Social care teams and Manager
  • Day hospital nurses
  • Occupational Therapist
  • Community Mental Health
  • Physiotherapist
  • PCT Pharmacy team
  • GP Practice staff (e.g. GPs, Elderly Care
    Co-ordinators)

24
Referral 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
25
Health 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)

26
Benefits 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

27
Case 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

28
Increasing 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

30
MDT 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)
32
Savings 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

33
Ongoing 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

34
Benefits 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
35
Lessons 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

36
Lessons learned - operational
  • Multidisciplinary working
  • Within and between teams
  • Flexible approach
  • Information sharing between different
    organisations
  • Resources
  • Early recruitment
  • Administrative support
  • Inclusion of psychology

37
Contacts
  • 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
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