OLDER AND BETTER: LIVING WELL AT HOME OR IN THE COMMUNITY RESHAPING CARE PRORGAMME

1. OLDER AND BETTER:LIVING WELL AT HOME OR IN THE COMMUNITY RESHAPING CARE PRORGAMME

2. Margaret Whoriskey JITTIM Eltringham, East Renfrewshire Trudi Marsha Lanarkshire

3. Our Vision: Older people in Scotland are valued as an asset, their voices are heard and they are supported to enjoy full and positive lives in their own homes or in a homely setting

4. Our Policy Goal: To optimise the independence and wellbeing of older people at home or in a homely setting

5. “Most older people (89.5%) do not receive ‘formal’ care in NHS continuing care, a care home or a home care service organised by social work agencies.”

6. “To put it bluntly, we are presented with a huge structural and financial challenge that cannot be fixed through efficiency savings or marginal changes to service provision on their own.”

7. Change Fund & Change Plans • £70 million 2011/2012– expected circa £300 million over 4 years (1 – 2 % of total spend on older people) • Bridging finance to lever improvement across the entirety of older people’s spend in health and social care • Partnership planning process – Health, Local Government, voluntary and independent sectors

9. Percentage of Plans including Each Category

10. Measuring progress • Support at Improvement Network event for development of Core Set of measures (with common definitions for all partnerships). COSLA endorse this approach. • Draft proposals issued in May to all partnerships. • Key messages from consultation (24 Partnerships): • Focus on outcomes where possible. • Make it manageable. • Core Set used in conjunction with locally determined measures • Data should allow more detailed analysis where appropriate Agreed set of Measures issued 4th July 2011

11. A: Nationally available outcome measures and indicators A1. Emergency inpatient bed day rates 75+ A2. Delayed discharges and accumulated beddays used by DDs A3. Dementia prevalence rates (from QOF) A4. Percentage of people aged 65+ who live in housing (rather than a care home or a hospital setting) A5. Percentage of time in last 6 months of life spent at home or in a community setting (further guidance to be issued) Recommend further use of: A6. Satisfaction/Experience measures people and carers (from the Community Care Outcomes Framework )

12. B: Local Improvement Measures Anticipatory and preventative care • B1. Proportion living at home who have an Anticipatory Care Plan shared 75+ • B2. Waiting times for a housing adaptation • B3. Proportion of people 75+ with a telecare package Responsive / flexible home care and carers • B4. Reduction in hours of support after reablement • B5. Respite care for older people per 1000 population Demand for acute care • B6. Rate of 65+ conveyed to A and E with principal diagnosis of a fall (SAS) Effective flow in acute care • B7. Proportion of frail emergency admissions who access specialty unit within 24 hours Use of long term residential care • B8. Rate and proportion of new entrants admitted from home; from acute hospital (by specialty); following intermediate care; graduate from emergency respite

13. C: Partnership resource use C1 Per capita weighted cost of accumulated bed days lost to delayed discharge C2 Cost of emergency inpatient bed days for people aged 75+ per 1000 population C3 A measure of the balance of care (e.g. split between spend on institutional and community-based care) IRF data will support use of these measures in particular

14. Anticipatory Care Planning and tacklingpolypharmacy Falls and fracture preventionManage transitions through re-ablement, Intermediate Care and Virtual Ward alternatives to admission Manage flow of older people at A&E and in acute care Dementia whole system demonstrators Telehealthcare demonstrators – eg DALLAS LTC ehealth demonstrators

16. East RenfrewshireReshaping Care for Older People Community Capacity Building

17. Overview • East Renfrewshire • Local context • Relationship and partnerships • Progress to date • Learning success points

18. East Renfrewshire • South of Glasgow • Giffnock, Newton Mearns, Barrhead, Clarkston • 90,000 population • High number 85+ • Relatively affluent

19. Foundations • Integrated CHCP • Changing Lives 2006 • Single Outcome Agreement • Talking Points and community care • outcomes • Working together for all our Futures (Council Strategy)

20. Relationships, Partnerships and ways of working • Level of trust and previous working together • Voluntary Action: • Third Sector Interface • Third Sector Forum • Thematic projects • Outcome focused planning • Understanding approaches i.e. asset building, community capacity building, co-production

21. Reshaping Care for Older People • CHCP and Voluntary Action Memorandum of Agreement • Formal governance structure • Change Fund: Funding staffing capacity with VA • Key aims • Community Capacity Building • Promotion of volunteering

22. Our Approach • Sound evidence base • Shared learning across partners to inform evaluation • Third sector engagement event • Develop the shared understanding • and developing a framework for • planning • Work programme in development

23. Logic model (draft)

24. Will it work? • Transformation is not only the preserve of • public services. • The achievement of positive outcomes involves • working with communities to build capacity. • Achieving the Talking Points outcomes leads to • greater resilience and reductions in reliance on • public services. • Will help shift the balance of care and • achievement of key Quality Outcomes.

25. Learning/factors of success • Foundation of community capacity building • understanding, knowledge and experience • in voluntary sector and health improvement • History and level of joint working • Shared understanding and ambition to • work together and do things differently

26. “Collaborative partnership working benefits all parties involved, maximises resources and ensures better results for older people” Helen and Jim also hear about the RSVP Assisted Shopping Service using the Wee Red Bus, accompanied by volunteer buddies and start to take part Through their contact with RSVP Jim and Helen find out about support services available through the Carers Centre & Alzheimer’s East Renfrewshire Project Meanwhile Levern Valley Older People’s Team refer Helen to VA Befriending Project for social support - on assessment it transpires that Jim also needs type of service of provided through ‘Chataway’ telephone befriending run & delivered by volunteers. RSVP start a weekly tearoom at underCOVER to encourage greater social interaction between people using the service and Jim and Helen come along RSVP “Wee Red Bus” hired by NHS Greater Glasgow & Clyde for 12 weeks to take patients to the Falls Clinic , including Jim who cares for his wife Helen who has Alzheimer’s VA Befriending Project Worker involved in setting up a seniors steering group to shape and develop use of the underCOVER building and Jim has agreed to become a member of the group Helen & Jim given information on the RSVP Medical Appointment Service run by ‘seniors’ volunteers using their own vehicles . Helen & Jim start to use the service for their GP appointments

27. Reshaping Care Older People Lanarkshire

28. Examples of funding approvals to date • Provision of medical services to 2 Local Authority care homes • Increasing capacity in Community Assessment Rehabilitation Service • More effective Old Age Psychiatry services • Integrated Discharge Facilitator – 3.0 posts • Hospital at Home Scheme/ Community Acute Care Elderly (ACE) • Roll out of re-ablement model • Implement Lanarkshire Falls and Bone Health Strategy • Supported transport home from A&E • Increasing capacity of community network support systems • Enhance Joint Equipment service

29. Lanarkshire Community ACE Pilot

30. The Perfect Storm? More Patients Less Doctors Better Quality Care Less Beds Less Resource

31. Over 75 Admissions(Percentage Growth)

32. Over 75 Admissions(Percentage Growth)

33. Admission Avoidance Hospital at Home

34. Admission Avoidance Hospital at Home Admit patients directly from the community avoiding physical contact with the hospital, or may admit from the emergency room. 10 RCTs (n=1333) “There is no evidence from the analysis to suggest that admission avoidance hospital at home leads to outcomes that differ from inpatient hospital care.”

35. Test of Concept Cumbernauld and Kilsyth c 3500 Over 75s All over 75yrs GP calls requesting admission ALL Nursing Home Residents (Any Age) “One Week Only”

36. Crisis! ACE? Within 1hr GP Community ACE Team First Assessment Treat Second Assessment Physio OT MDT Homecare Equipment Discharge Referral Investigate

37. Case Study One 86 year old lady with history of confusion who lives with her husband. Fall from her bed last night and was returned to bed by SAS. GP contacted by family as experiencing general deterioration, reduced mobility and increased confusion. ERC had been contacted by GP to arrange admission for investigation and treatment.

38. Management Admin contacted husband advised of response time, requested medical notes Nurse attended within 15 minutes and carried out a full system examination, 12 lead ECG, bloods, urinalysis, continence assessment, developed working diagnosis and initial management plan – UTI with delirium. Husband also identified as having a chest infection, liaised with GP Consultant reviewed working diagnosis, prescribed antibiotics, medication review, reassured family Functional review undertaken by AHP to support mobility during acute illness 7 hours Re-ablement / week Reviewed daily for 2 days Pre Barthel 48 Post Barthel 53

39. Case Study Two Contacted by Merrystone to review 78 year old man who lives with his wife. He had experienced 3 falls in past 24 hours. Had existing homecare support 7/7 x2. Merrystone reported no other issues other than regular falls. Pattern of regular admissions monthly to acute.

40. Management Admin contacted wife, advised of response time and requested medical notes AHP attended within 30 minutes, obtained history, undertook functional assessment and identified new balance issues requiring medical review, walking aid provided Nurse attended obtained full history and conducted full system examination, 12 lead ECG, bloods, urinalysis, identified complex medication issues requiring consultant review Consultant reviewed developed working diagnosis- complex polypharmacy resulting in parkinsonism symptoms, linked with CMHT and family re medication changes, liaised with GP Pre Barthel 52 Post Barthel 52

41. Management Consultant reviewed developed working diagnoses:- Complex polypharmacy Parkinsonism symptoms (?Valproate related) (Postural instability, freezing, rigidity, tremor) UTI Complex Psychiatric History Referred to CMHT and family re medication changes, liaised with GP Conservative plan agreed to avoid minimise risk and make home life manageable Pre Barthel 52 Post Barthel 52

42. Case Study Three 81 year old lady who lived with her husband. Husband who was main carer recently admitted to Monklands. Neighbours concerned as lady seen wandering and deterioration No food / shopping in house. SW had contacted headquarters to arrange emergency respite placement

43. Management Admin arranged medical notes and informed GP Nurse contacted SW to obtain full history. Full systems examination undertaken. 12 lead ECG, bloods, urinalysis. No acute medical issues identified. Review arranged by CMHT. Son contacted to arrange shopping. Consultant stopped all medication and excluded any other acute issues liaised with GP Re-ablement 7 hrs/ week

44. Learning Testing concept It is possible to provide safe community alternatives to acute care Embed model in existing community services Workforce development - new roles acute and community exposure needed recruit attitude not aptitude Staff ability to manage new levels of risk essential Rapid access to all services needed Transport – x-ray

45. Robopractitioner?

46. Next Steps? Phase 2 - Further larger pilot (c 9,000 over 75s, 6 months?) Staff Training and Recruitment Protocol / Guideline Development / Referral Pathways Links with Primary Care / Psychiatry / Social Work IT development Telemedicine Evaluation Phase 2

47. SUB HEADING TO BE Change Plans: Supporting Partnerships • JIT lead for all Partnerships – bespoke programmes and thematic • Reshaping Care Improvement Network • National Improvement Measures • Joint Commissioning Strategies 2012- 2020

48. Improvement Network • Established on 1 April 2011 • Programme of events, web ex sessions • E Bulletin • Regional groups being explored

49. EVALUATION • Third sector /community capacity building – proposal under development • Scottish Centre for Public Health Collaboration

50. MID YEAR PROGRESS REPORT • To report on progress with implementation and use of change fund and committed spend • First report end of August 2011, update for December 2011