Transcript Gateshead CCG

Gateshead Care Home
Programme
Marc Hopkinson
Our Mission & Vision
Mission:
Working together to improve the health of Gateshead
Vision:
 Care for people in a seamless way
 Ensure commissioning is clinically led and driven by
patients and carer involvement
 Improve the quality of health services
Quality of
Care
Working
together
Compassion
Improving
Lives
Respect &
Dignity
Everyone
Counts
Needs increasing: scale
Now
2030
• 203,000 population
• 191,000 population
• Aged 65 + increase of 1/3
• 18% over 65 years
(34,000 – 45,000)
• 3.7% over 85 years
• Over 85 years - 90% increase
• 0.85% living in care
homes
(3,900 to 7,500)
• Median length of stay 20
months
(23 in Nursing, 27 in
Residential)
Quality not right now
Frailty is the issue
• Care is reactive … we need specialist proactive
• Variation e.g. multiple practices causes problems
• Communication issues across settings admission/discharge
• Care planning inc advanced care (In and OOH)
Specialist Care Homes
(including Learning Disability, Promoting
Independence Centres and Specialist Mental
Health)
Nursing Homes
15 homes (907 patients)
Residential Care Homes
17 homes (596 patients)
Older People supported to live at home aged 65+
(4273 patients)
Older People (40, 000 aged 65 +)
Aim:
To improve the care of patients and families
through more integrated proactive care
Objectives:
Improve each care setting and bring them into
a ‘frailty team’
• Increasing skills and understanding in homes.
• Changing reactive primary care delivery to a
proactive model involving weekly visits by a
lead GP from the care homes linked practice
• Comprehensive care planning and MDT case
management led by specialist nurses at the
weekly ward rounds with ongoing support to
homes
Objectives (Cont)
• Bringing specialists into a virtual team to
support when needed and improving
communication between
• Reduce avoidable hospital admissions
• To be cost saving
Pilot Results
• Investment of approx £50k
• 98 patients case managed
• 45.5% reduction in admission rates
based on 2008/09 data
- admission days 440
- admission costs £243,146
• ‘You gave me my
father back’
• Savings assuming same
conditions/reasons for admission for total
care home population in Gateshead:
- 6763 bed days
- £3,730,446
Inpatient
Outpatient geriatrician
Specialist input (OAP, SALT, Physio)
Lead GP, Specialist Nurse
Care home staff
Patients, Carers and families
Expanding this across Gateshead
• Care homes trained
• 28/34 Care homes linked to practices
• 6 specialist nurses proving comprehensive
reviews, care planning, liaising and reactive
care
• Medicines Management Team
• GHFT Geriatrician
• Laptops
• Key partners- LA, OA Psychiatry
Emergency Admissions per 10,000
2,500
Reviews/ Winter
2,000
Re- launch of LES
1,500
1,000
500
0
Nursing Home Patients with Care Plans
Gateshead (aged 65+)
Gateshead (all)
Specialist
Nurses
Commissioned
Average Length of Stay
25
20
15
10
5
0
Nursing Home Patients with Care Plans
Gateshead (aged 65+)
Gateshead (all)
The Project Group
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Dr Mark Dornan
Lesley Bainbridge
Lynne Shaw
Dr Daniel Cowie
Dr Louise Crabtree
Marc Hopkinson
Any Questions?
http://gatesheadccg.nhs.uk
/about-us/case-studies/